
(lass 



Book 



COPYRIGHT DEPOSIT 



Post-mortem Pathology 

A MANUAL OF POST-MORTEM EXAMINATIONS 

AM) THE INTERPRETATIONS TO BE 
DRAWN THEREFROM 

A PRACTICAL TREATISE TOR STUDENTS AND PRACTITIONERS 



HENRY W. CATTELL, A.M., W.D. 

VMERICAN EDITOR AND TRANSLATOR OF ZIEGLER'S SPECIAL PATHOLOGY; PATHOLOGIST TO Till-: WIS 
PHILADELPHIA HOSPITAL FOR WOMEN; AND SOMETIME DIRECTOR OP THE JOSEPHINE I 

CLINICAL LABORATORY OF THE PENNSYLVANIA HOSPITAL; SENIOR CORONER'S PHYSICIAN OF 
PHILADELPHIA; PATHOLOGIST TO THE PRKSBYTKRIAN AND PHILADELPHIA HOSPI1 W 
PROSECTOR OF THE AMERICAN ANTHROPOMETRIC SOCIETY; DBMOM 
OF MORBID ANATOMY IN THE UNIVERSITY OF PENNSYLVANIA 



SECOND, REVISED AND ENLARGED EDITION 



COPIOUSLY ILLUSTRATED WITH COLORED PI VTES VND FIGURES 



"RottO dal mentn insm Jove- si trulla. 
Tra le gambe pendevan le minuuia; 
La corata pareva. e il tristo 
Che merda f I ' tranpifcU." 

IMMI 



PHILADELPHI \ WD I ( >\l M >\ 

J. B. LIPPINCOI I O IMPANY 






LIBRARY of CONGRESS 
Two Copies rteceivw 

FEB 4 1905 

Copyritfiu tuiry 

■cuss a xxc, jyoi 

COPY B. 



Copyright, 1903, by J. B. Lippincott Company 



Copyright, 1905, by J. B. Lippincott Company 



PRINTED BY J. B. LIPPINCOTT COMPANY, PHILADELPHIA, U.S./ 



TO THE MEMORY OF 
MY FRIENDS 

DR. THOMAS G. MORTON 

DR. THOMAS S. KIRKBRIDE, JR. 



PREFACE TO THE SECOND EDITION 

To this edition have been added a chapter on the pathology of the 
bones and joints, a summary of the literature on legal medicine and 
the technic of post-mortem examinations, and twenty-seven new 
illustrations, including six in colors. The chapters on bacteriologic 
investigations, medicolegal suggestions, and the examination of the 
exterior of the body have been thoroughly revised, and much other 
matter has been rearranged and wholly or in part rewritten. 

I am indebted to Dr. Adelaide W. Peckham, Professor of Bac- 
teriology in the Woman's Medical College of Pennsylvania, for sug- 
gestions regarding Chapter XXIII, Bacteriologic Investigations, and 
to Dr. Ellen P. Corson-White for her assistance upon Chapter V, 
Examination of the Exterior of the Body, and upon the references 
contained in Chapter XXIX. Those who helped me in the prepara- 
tion of the first edition of this work have again performed a similar 
service, for which I am grateful. 

HENRY W. CATTELL. 

3709 Spruce Street, Philadelphia, January 18, 1905. 



PREFACE TO THE FIRST EDITION 

This book has been written for those who ought to make autopsies 
but do not and for those of whom such investigations are required, as 
medical students, hospital interns, and coroner's physicians. While 
it would seem to be quite needless to urge upon a practitioner the 
importance of performing post-mortem examinations, it is a fact that 
extremely few are made outside of hospitals, and even there necrop- 
sies are usually conducted by the untrained resident or the substitute of 
the pathologist. It cannot be questioned, however, that the physician 
who improves his opportunities for pathological study *on the cadaver 
will be a better diagnostician and safer therapist, will have a more 
enduring reputation, and will receive a greater pecuniary return than 
he who neglects such means of investigating morbid processes. 

While the author has mainly relied upon his personal experiences 
in the preparation of the subject-matter of this manual, he has freely 
used classifications and material derived from Orth's Pathologisch- 
Anatomische Diagnostik, Osler's Practice of Medicine, Nauwerck's 
Sections-Technik, and other publications mentioned in the foot-notes 
and in the text. He is, therefore, much indebted to these authorities, 
as well as to Dr. George Robinson and Mr. Louis Schmidt for 
most of the drawings, all of which were prepared under the writer's 
direction, to his friends and former students Drs. William S. Wads 
worth, Mary E. Lapham, E. D. Burkhard, and Edward Lodholz 
for suggestions in the preparation of the book, and to that excellent 
proof-reader Mr. T. Grow Taylor for seeing the work through the 
press. 

HENRY W. CATTELL. 

3709 Spruce Street, Philadelphia. March 31, 1903. 



CONTENTS 



CHAPTER PAGE 

I. General Considerations I 

II. Order of Examination and Post-Mortem Records 13 

III. Post-Mortem Instruments and How to Use them 28 

IV. The Care of the Hands and the Treatment of Post-Mortem 

"Wounds 38 

V. Examination of the Exterior of the Body 46 

VI. Technic of Opening the Abdominal Cavity and the Topographic 

Examination of the Parts contained therein 79 

VII. Technic of Exposing the Thoracic Cavity and the Critical 

Examination of the Parts contained therein 92 

VIII. Diseases of the Heart, Blood, Blood-Vessels, and Lymph-Vessels 113 

IX. Diseases of the Respiratory Tract and Accessory Parts 141 

X. Critical Examination of the Organs of the Abdominal Cavity . . 159 

XI. Diseases of the Genito-Urinary Tract 199 

XII. Diseases of the Liver and Pancreas and their Ducts 213 

XIII. Examination of the Skull and Brain 225 

XIV. Examination of the Spinal Canal and Cord 242 

XV. Diseases of the Brain and Cord 246 

XVI. Examination of the Nasopharynx, Eyes, and Ears 256 

XVII. Examination and Diseases of the Bones and Joints 261 

XVIII. Post-Mortem Examination of the New-Born 275 

XIX. Restricted Post-Mortem Examinations 280 

XX. Restoration and Preservation of the Body 283 

XXI. Diseases due to Micro-Organisms, Parasites, and H.-ematozoa . . . 290 
XXII. The Preservation of Tissues for Macroscopic and Microscopic 

Purposes 326 

XXIII. Bacteriologic Investigations 346 

XXIV. Weights and Measures 357 

XXV. Comparative Postmortems 373 

XXVI. Medicolegal Suggestions 397 

XXVII. The Prussian Regulations for the Performance of Autopsies in 

Medicolegal Cases 436 

XXVIII. Usual Causes of Death ; their Nomenclature, Complications, 

and Synonyms 448 

XXIX. References 465 

XXX. Glossary Index 489 



LIST OF ILLUSTRATIONS 

PLATE PAGE 

1. Outline Chart of Human Body Second page of cover 

II. Normal Size of Familiar Objects 18 

III. Post-Mortem Scale for estimating Haemoglobin. Moisture Scale. 

Third page of cover 

IV. Chart of Tumors 134 

V. Bacteriologic Chart 350 

VI. Powder Markings 409 

FIG. 

i. Portable post-mortem table 8 

2. Body in coffin prepared for post-mortem examination 8-9 

3. Post-mortem table for babe, constructed of chairs and drawing-board . . 8-9 

4. Post-mortem room of Ayer Clinical Laboratory, Pennsylvania Hospital 8-9 

5. Refrigerator box for preservation of bodies 9 

6-8. Working plans for preparing refrigerator box for storage of bodies .... 10 
9, 10. Plans for post-mortem table 10-1 1 

11. 12. Working plan and drawing of combination electric, gas, and water 

fixtures for post-mortem table 11 

13. Section- or cartilage-knife 28 

14. Cartilage-knife with projection on back 28 

15. Post-mortem knife with a faulty point and improper belly 28 

16. Coplin 's brain-knife 28 

17. Bread-knife for incising large organs 28 

18. Valentine's knife 28 

19. Pick's myelotome 28 

20. Forceps ; saw ; needles ; hammer ; steel tape measure ; hone and strop ; 

and rounded hard-wood handle for scalpel 28-29 

21. Saw for post-mortem work 28-29 

22. Butcher's saw for post-mortem work 28-29 

23. Hey's saw 28-29 

24. Metacarpal saw 28-29 

25. Luer's double rhachiotome 28-29 

26. Cryer's electric surgical engine 30 

27. Strong scissors with short blades 29 

28. Scissors with one dull point and with bent handles 29 

29. Separate-bladed scissors 29 

30. Proper form of enterotome 29 

31. Improper form of enterotome 29 



x LIST OF ILLUSTRATIONS 

"G. PAGE 

32. Proper form of costotome 30 

33. Improper form of costotome 30 

34. Steel hammer 30 

35. Steel side chisel 30-31 

36. Curved chisel 30-31 

2>7. Brunetti's curved spinal chisel 30-31 

38, 39. Various forms of forceps 30-31 

40. Straight grooved director 30-31 

41. Satterthwaite's calvarium clamp 30-31 

42. Iron clamp for removing brain 31 

43. Bigelow clamp 31 

44. Folding head-rest 31 

45. Cornell folding clamp 32 

46. Measuring stick 32 

47. Raspatory 33 

48. Pocket-case of instruments 32 

49. Cones for measuring orifices 32-33 

50. Glass balls for measuring orifices 32-33 

51. Linen twine wrapped of proper length ready for use 32-33 

52. Formad's pocket-case for post-mortem instruments 32-33 

53. Method of holding cartilage-knife 33 

54-56. Lines showing various methods for opening thoracic and abdominal 

cavities 79 

57. 58. Method of making initial incision over sternum 78 

59, 60. Method of removing skin over sternum and ribs 78-79 

61. Method of opening abdominal cavity 78-79 

62. Method of incising ribs 78-79 

63, 64. Method of separating sternoclavicular attachment 79 

65. Method of incising first rib and sternoclavicular articulation with costo- 

tome 92 

66. Severance of diaphragm 92 

67. 68. Removal of bony parts covering thoracic cavity 92-93 

69. Breastplate after its removal from body 92~93 

70. Methods of enlarging abdominal cavity and of protecting operator's 

hands from in j ury 92-93 

71. Method of opening pericardium 93 

72-74. Lines for opening heart 102 

75. Method of removing heart from body 93 

76. Situation of pulmonary veins 104 

77. Method of opening right auricle 104-105 

78. Method of opening left ventricle 104-105 

79. Method of opening pulmonary artery 104-105 

80. Interior of left auricle and ventricle fully exposed 105 



LIST OF ILLUSTRATIONS x i 



FIG. 



81. Reconstruction of heart after its examination 105 

82. Methods of opening lung 108 

83. Lung laid open for minute inspection 108-109 

84. Method of opening pulmonary vein and its branches 108-109 

85. Method of opening bronchi and their ramifications 109 

86. Method of removing tongue, tonsils, oesophagus, trachea, etc., in a single 

piece 1 10 

S7. Examination of organs of neck 1 10-1 1 1 

8^. Method of opening trachea posteriorly 110-11 1 

89. Examination of trachea and vocal cords 110-111 

90. Finger method of tying intestine 165 

91. Method of tying intestine preparatory to its removal 11 1 

92. Bucket method of opening and cleansing intestines in 

93. Method of removing small intestines 166 

94. Opening of small intestines after their removal from the body 166 

95. Method of incising kidney with its ureter still attached 166 

96. Method of opening kidney 177 

97. Method of finishing opening of kidney 178 

98. Method of removing capsule of kidney (without gloves) 166-167 

99. Method of removing capsule of kidney (with gloves) 166-167 

100. Relations of pancreas, kidney, ureter, adrenal, and solar plexus 182 

101. Position for body in examination of rectovaginal region 166-167 

102-109. Post-mortem extirpation of bladder, uterus, and adnexa through 

vagina, and subsequent restoration of parts 167 

1 10. Method of opening uterus 183 

in. Uterus and adnexa after being opened 184 

112-114. Author's method of examining testicles, epididymis, spermatic cord, 

etc., without disfigurement 186 

115. Method of opening seminal vesicles 186-187 

116. Relation of gall-ducts and duodenum 186-187 

117. Examination of bile-ducts 186-187 

1 18. Method of examining stomach 187 

1 19. Removal of liver from body 187 

120. Method of incising liver 194 

121. Starting-point of incision in removal of brain 226 

122. Parting of hair so as not to injure it in removal of brain 226 

123. Method of sawing skullcap 226-227 

124. Angular method of removing brain 226-227 

125. Method of breaking up inner table with an old knife after sawing. . 226-227 

126. Method of drawing off skullcap with a retractor 226-227 

127. French method of opening skull 228 

128. French method of opening dura 229 

129. Appearance of dura mater after removal of calvarium 227 



xii LIST OF ILLUSTRATIONS 

1 u - PAGE 

130. Appearance of brain after removal of dura 230 

131. Method of removing brain from skull 230-231 

132-135. Virchow's method of dissecting brain 230-231 

136-138. Virchow's method of dissecting brain (continued) 236 

139. Nauwerck's method of dissecting brain 236-237 

140. Basal ganglia, with cerebellum, pons Varolii, and medulla oblongata 

attached, in Meynert's method of dissecting brain 236-237 

141. Flechsig's, Brissaud's, and Dejerine's transverse sectioning of brain 237 

142. Dejerine's incisions for brain previous to hardening 237 

143. Lines for removing spinal cord and brain, the latter through a small 

triangular occipital incision 242 

144-149. Removal of spinal cord 244-245 

150. Method of examining nasopharynx, eyes, and ears 256 

151 
152. 
153. 
154. 
155 
156. 



Harke's method of examining nasopharynx 245 

Restoration of parts in Harke's method of examining nasopharynx 245 

Use of chain saw in examining auditory apparatus 259 

Examination of umbilical vessels 276 

Examination of ductus arteriosus 276 

Removal of spinal cord in child 276-277 

I 57> !58. Method of examining the femur for syphilitic osteochondritis. .. .276-277 
159, 160. Method of examining nasal cavities, antrum of Highmore, etc 277 

161. Slee's method of fixing skullcap 284 

162. Author's method of holding skullcap in place 284 

163. 164. Sewing up body 284-285 

165. Method of withdrawing blood from a body previous to injection of 

embalming fluid 284-285 

166. Injection of body with embalming fluid 284-285 

167. Refrigerating room 285 

168. Preparation of bodies with preservative fluids after removal from re- 

frigerating room 285 

169. Method of determining rectal temperature in a guinea-pig 354 

170. Animal holder 354 

171. Method of performing peritoneal injection in a rabbit 354~355 

172. Ear method of inoculating rabbit 354~355 

173. Post-mortem examination of guinea-pig 354~355 

174. Post-mortem examination of rabbit 355 

I75 — 1 77- Post-mortem examination of horse 377, 37&> and 380 

178. Lines for opening cephalic cavities of horse 387 

179. Lines for opening cranial cavity of horse 387 

180. Lines for exposing cranial and nasal cavities in ruminants 390 

181. Appearance of cranial cavity in a cow 390 

182. Post-mortem examination of dog 392 

183. Exposure of oral and pharyngeal cavities in a dog 393 



POST-MORTEM EXAMINATIONS 

CHAPTER I 

GENERAL CONSIDERATIONS 

Historical. — The Code of Hammurabi, the Old Testament, and 
the ancient classics abound in references to violent death and the shed- 
ding of blood, but are silent up to the time of Herophilus (320—250 
B.C.) as to any opening of the body for legal or pathologic purposes. 
It is known, however, that the Jewish priests examined the carcasses 
of animals killed for food to detect impurities, and the knowledge of 
anatomy displayed at an early date shows that human dissection must 
have been practised. In the Middle Ages postmortems were performed 
in cases of poisoning, Charles V. in 1530 empowering the judge to 
call in physicians as experts. In 1562 Pare made a judicial post- 
mortem, and thus established a medicolegal status which has continued 
until the present time. The office of coroner is an old and important 
one. It was created during the reign of King Athelstan, 925 a.d., 
and its duties were clearly defined soon after the Norman conquest. 
From England the institution was brought to America by the colonists, 
where the first post-mortem examination appears to have been made 
in 1639 in a case of fracture of the skull, and the second in 1643, death 
being caused by a bullet wound. 1 The authority of the coroner to hold 
an inquest is not confined to the body of a person who may have died 
within his jurisdiction, but extends to all cadavers brought within his 
territory, no matter where death may have taken place. (Becker.) 
Massachusetts in 1877 abolished the office of coroner, substituting 
therefor medical examiners, and the New York legislature in 1904 
passed a bill for a similar purpose, which was, however, returned to 
the Governor with a veto by the Mayor of New York City. 

1 Hoadley, Proceedings Conn. Med. Soc, 1892, pp. 207-17, quoted by Steiner, 
Johns Hopkins Bull, Aug., 1903. See also Packard, Phila. Med. Jr., Feb. 17, 1902; 
Editorial, Jr. Amer. Med. Assoc., Oct. 28, 1893, p. 661. 



2 POST-MORTEM EXAMINATIONS 

Definition. — Postmortem, autopsy, and necropsy are synony- 
mous terms applied to the systematic exposure and critical examina- 
tion of the cadaver with the object of determining the cause of death 
or of studying morbid anatomy in any of its various aspects. Other 
synonyms employed are necroscopy, mortopsy, section, sectio ca- 
daveris, sectio anatomica, and post (colloquial). A medicolegal post- 
mortem differs from an ordinary postmortem only in the application 
of the information obtained to the furtherance of the ends of justice. 
The German word Obduction is correctly applied only to a medico- 
legal postmortem. The use of the word " autopsy," in the sense now 
generally accepted, was first made by v. Riihl, Crighton, and Bluhm, 
in an account by them of the examination of the body of the Em- 
press Maria Feodorowna, of Russia. 1 

Purpose. — As the object of a post-mortem examination is the 
acquisition of exact data, the method of procedure should be scientific 
and systematic. This is especially important in medicolegal cases, 
which frequently involve not only the reputation and liberty, but even 
the life of a human being. If the examination be conducted in a 
perfunctory or desultory way, some detail of the greatest importance 
may be overlooked or the information obtained may be so ill arranged 
as to be practically valueless for statistical or demonstrative pur- 
poses. In no other department of medical science are the faculties 
of observation and discrimination more vigorously called into play, 
and in none other are sound knowledge and accurate work so indis- 
pensable. 

Opportunities for the study of normal structures offered by post- 
mortems upon presumably healthy individuals killed by accident should 
not be neglected, as thorough familiarity with the appearance of the 
various organs and tissues in their normal condition is necessary in 
order that morbid changes or slight variations from health may be 
recognized. Such subjects also often afford favorable oportunities 
for the study of the earliest manifestations of disease, particularly 
in case of tumors and the infective granulomata. New anomalies 
also may be found, and these, as in the case of polydactylism, may 
be studied in order to support or disprove Mendel's and Galton's laws 
of inheritance. As the science of medicine advances, new discoveries 

1 Sahb. med.-ch.ir. Ztg., 1829, vol. i, p. 107; Foster's Encyclopedic Med. Diet., 
p. 516, quoting from Kraus's Kritisch-etymologisches medicinisches Lexikon. 



GENERAL CONSIDERATIONS 3 

necessitate a constant revision of the statistics of even the most com- 
mon diseases. 

Autopsies present exceptional opportunities for reviewing the 
study of anatomy and also for acquiring dexterity in the practice of 
surgery. To this end, it is permissible in suitable cases to perform 
surgical operations that entail no visible disfigurement of the body. 
Some of the more recently devised surgical procedures, such as the 
decapsulization of the kidney, the mechanical irritation of the hepatic 
peritoneum, the transplantation of ovarian tissue, the Lorenz opera- 
tion for congenital dislocation of the hip, Gersung's injection of 
paraffin for the correction of deformities, the formation of an anterior 
and posterior cusp in the cervical os to prevent conception without in- 
terference with the outflow of the menstrual fluid, etc., will at once 
suggest themselves as being worthy of practice upon the cadaver as 
opportunity occurs. 

Permission. — When a postmortem is desired, the first step in 
every instance is to secure the legal right to make it. When not per- 
formed by order of a regularly appointed officer of the law, consent 
(preferably in writing) should be obtained from the next of kin to 
the deceased, or, in the absence of relatives, from the person in charge 
of the funeral. The feelings of friends and relatives must be fully 
respected : scientific zeal is no excuse for wounding them. In a suit 
for damages brought a few years ago against a Philadelphia hospital 
on account of a postmortem that had been made without the consent 
of the nearest relative, the judge severely deprecated the procedure, 
but held that no damages could be recovered in this instance, as the 
hospital was a charitable institution. 

The method to be pursued in gaining permission will depend 
largely on the nature of the case, but the exercise of tact will nearly 
always overcome sentimental objections and secure consent except 
where religious scruples stand in the way. Thus, one resident in a 
hospital will obtain the opportunity of making an autopsy upon almost 
ever}- patient dying in the wards during his term of service, while 
another interne of the same institution will, for one reason or another, 
meet refusal in the great majority of his cases. The curiosity of 
relatives and friends may be aroused, or the humane plea of doing 
no harm to the dead but possibly much good to the living will often 
appeal to the better judgment of those from whom consent is to be 
obtained. The author recalls a case in which those interested expressed 



4 POST-MORTEM EXAMINATIONS 

great satisfaction on learning that death was not due, as had been 
diagnosed during life, to consumption. An invitation to a member of 
the family to be present at the postmortem or a promise to make a 
death-mask (see page 289) will often secure the desired permission. 
The laity should be encouraged to ask for an autopsy. A carefully 
performed postmortem often secures ready consent to, or even a volun- 
tary request for, others in the vicinity in which the physician resides. 
The blank forms which accompany insurance papers often contain 
the query, "Was an autopsy made?" and an affirmative answer 
greatly strengthens the holder's claim. Indeed, insurance companies 
should encourage the making of autopsies, as it is to their own pecu- 
niary advantage so to do. Our Boards of Health, with their enormous 
power for good or evil, in some States have the legal right to compel 
the performance of postmortems, a prerogative that has already been 
advocated more warmly by the lay press than by the profession at 
large. The offer of a small sum of money will often secure permis- 
sion to make a necropsy among the indigent foreigners who are so 
numerous in our large cities, but a threat to refer the case to the 
coroner unless permission is voluntarily granted should never be em- 
ployed. Undertakers who oppose the making of autopsies should not 
be recommended. 

The pecuniary value that dead bodies may have sometimes gives 
rise to legal contests. The Supreme Court of California has decided 
that one cannot dispose of his own corpse by will. A man bequeathed 
his body to the managers of a medical college, in the hospital of which 
he had been treated, to be used for scientific purposes. The man's 
relatives claimed the cadaver, and applied to the courts for an injunc- 
tion restraining the medical college from using it. The kinsfolk won, 
the court holding that the custody of the corpse and the right of 
burial belong to the next of kin. 1 There are in America and in France 
several societies the members of which sign cards granting permission 
for the performance of postmortems on their bodies: it would, how- 
ever, on account of the decision of the court just referred to, seem best 
to have the card endorsed by the legal heirs. 

Yet even when permission has been given circumstances may pre- 
vent the performance of the autopsy. Thus, in the case of Phillips 
Brooks, who was a member of the American Anthropometric Society, 

1 American Medicine, April 6, 1901. 



GENERAL CONSIDERATIONS c 

the prosector of the society, on reaching Boston, could not perform 
the postmortem, as, a public funeral being universally desired, the 
body had been placed in an hermetically sealed coffin, death being due 
to diphtheria. 

In the case of Loesch vs. the Union Casualty and Surety Co., 1 
the Supreme Court of Missouri held that the autopsy made without 
notice to the company was no bar to recovery. The physicians making 
the examination and the mother of the deceased, who tacitly assented 
to its performance, were in ignorance of the fact that there was a 
clause in the policy stating that if a postmortem was held without 
notice to the company in time to have its medical adviser present all 
claims under the policy should be forfeited. As soon as the error 
was discovered, which was in time for a re-examination, the company 
was notified. 

There should be a law permitting post-mortem examinations of 
the bodies of all persons dying in charitable institutions. Such a rule 
exists in the hospitals in Germany, and this precedent for some time 
prevailed in the Philadelphia Hospital with practically no opposition, 
until a lawsuit, now pending, caused it to be abolished. In cadavers 
allotted to the anatomical board care should be taken not to destroy 
the arteries commonly used for injection. If in the course of an 
autopsy conditions are found which indicate foul play, as injuries or 
the presence of poison, the examination should be immediately sus- 
pended, and steps at once taken to have the coroner or other legal 
officer take charge of the case. If properly authorized by the coroner 
or the person who is legally acting in his stead, the examination may 
proceed in the manner prescribed for conducting medicolegal post- 
mortems. 

When portions of the body are desired for preservation or for 
future study, permission to remove them should be obtained from 
some one connected with the household, though not necessarily from 
the nearest relative, as in gaining consent for the performance of 
the autopsy; it is, of course, unnecessary to tell how much is to be 
taken away ! Should, however, the person authorizing the autopsy 
forbid the removal of any portion of the body from the house, no 
specimens should be taken. Consent can nearly always be obtained 
for the removal of small pieces of tissue for microscopic purposes, even 



1 Jr. Amer. Med. Assoc, September 26, 1903. 



6 POST-MORTEM EXAMINATIONS 

when permission to take away larger specimens is refused. In the 
necropsy on the body of President McKinley, the bullet which pro- 
duced the fatal wound was not found, because a member of the 
family objected, though without legal right so to do, to the further 
continuance of the search, and it was only with the greatest difficulty 
that consent was obtained to remove portions of the body for micro- 
scopic study. In France the law forbids the extraction of teeth with- 
out special administrative authorization. (Letulle. ) The careless 
handling of specimens removed at autopsies, especially those contain- 
ing pathogenic organisms, and the culture of the more virulent bacteria 
in our laboratories are sources of danger to the public that will, 
no doubt evoke legislative restrictions in the near future. For the 
protection of their patients, residents on duty in the surgical and 
gynaecological wards of our hospitals should be forbidden to make 
autopsies, and they should not be tempted to break this rule by a 
request to assist at a postmortem, even though no one else be available 
to open the body. 

Those Present. — To one who makes many autopsies a capable 
assistant and a trained attendant are invaluable. Anticipating what is 
wanted of them, they render prompt aid without being asked. In order 
to familiarize an assistant with one's method of work, it is a good plan, 
except in important cases, for the experienced pathologist to alternate 
with him, he himself often performing the duties of an assistant. Pro- 
fessional friends, especially those wdio saw the patient during life, 
should be invited to be present at the autopsy ; the scrutiny of critical 
eyes undoubtedly ensures more careful work. Besides, in medicolegal 
cases the responsibility of making an autopsy in which the evidence 
obtained may be sufficient to convict a person of the gravest of crimes 
is often too great to be borne alone. Before work is begun, the rela- 
tives and friends should be tactfully requested to leave the room. The 
nurse should be within calling distance, and the undertaker or his 
assistant should remain in the room, as he can often render valuable 
aid. 

While those present are prone to give advice that is useless, the 
suggestions made by them are frequently of great value. Courtesy 
demands that a guest should not be too forward in offering advice, 
but should always be ready to render such assistance as the operator 
may need or request. The one making the autopsy is in command 
and is responsible for the success or failure of the work entrusted to 



GENERAL CONSIDERATIONS j 

him. Letulle lays great stress upon the prohibition of smoking during 
the performance of the postmortem. 

Time. — The time allowed to elapse after death before making an 
autopsy depends upon the circumstances of the case, and may vary 
from a few minutes to several days or even months. The examina- 
tion should never be deferred longer than is absolutely necessary, 
as the entire cadaver is soon invaded by bacteria, and nuclear figures 
and cellular elements quickly lose much of their value for microscopic 
study. But the feeling of warmth imparted to the hands of the 
operator while making a necropsy soon after death, especially where 
there is much elevation of the temperature of the cadaver, as in fatal 
cases of heat-exhaustion or atropine-poisoning, is so repugnant to 
one's sensibilities that sufficient time should always be allowed for the 
temperature of the corpse to fall to a point inconsistent with suspended 
animation. In Xew York State a postmortem must immediately fol- 
low an electrocution inflicted as punishment for crime ; it is popularly 
believed that in at least one case the criminal was not killed by the 
electric current. The suit brought in the case of Bishop, the so-called 
mind-reader and cataleptic, where the necropsy was made immediately 
after death, will also be recalled in this connection. The law in 
Germany is that at least twenty-four hours should elapse after death 
before the performance of the autopsy is begun. 

The time required for the completion of a postmortem depends, 
of course, upon the conditions under which it is performed, upon the 
nature of the case, and upon the skill of the operator. In favorable 
cases the author has removed the brain in less than three minutes 
from the time of making the preliminary incision, and has made 
an entire postmortem examination, including the removal of the cord, 
in less than nineteen minutes. On the other hand, eight hours of 
uninterrupted work have been consumed by him in the performance 
of one autopsy. In a hospital the time usually required for a necropsy 
is about an hour and a half. Virchow considered that three hours' 
work was ordinarily sufficient to complete a medicolegal postmortem 
according to the Prussian regulations given in Chapter XXVII., and 
that in certain cases this time might be reduced by one-third. It is 
stated that Rokitansky x performed over thirty thousand autopsies, 

1 Preface to the Sydenham Society's translation of Rokitansky's Patho- 
logische Anatomie. 



8 POST-MORTEM EXAMINATIONS 

which would hardly allow an average of an hour for each. Kolisko, 
of Vienna, sometimes made five or six postmortems in a morning, and 
the author himself has more than once performed ten within twenty- 
four hours. Owing to lack of time, the surgeon or clinician may 
wish the necropsy to be made with more celerity than is consistent 
with thoroughness. As he often merely desires to ascertain a certain 
fact or to observe a single organ, he can generally be accommodated 
in a few minutes, and the examination afterwards completed in the 
routine manner. The performance of the autopsy may take but a 
short time in comparison with that required for the proper preparation 
and study of the tissues. Indeed, the collection and preservation of 
material for future investigation by the microscopist, chemist, ex- 
perimentalist, and bacteriologist are often the most important part of 
the process, for an error made at this stage may be irremediable. As 
Virchow aptly said, " A postmortem does not admit of repetition, 
whereas in a clinical examination at the bedside any omission may 
ordinarily be rectified at a subsequent visit." 

Place. — The place at which a post-mortem examination is to be 
made is rarely a matter of choice, especially in private practice, but 
it should always be where the best light is obtainable. Daylight from 
the north, such as is sought by artists, should be preferred. If the 
autopsy must be made after dark, a combination of the electric and 
Welsbach lights is the most satisfactory artificial illuminant. Orth 
suggests that a good substitute for daylight may be obtained by 
allowing the artificial light to pass through a glass flask containing 
water slightly colored with methylene blue. Such a flask may be 
used also as a condenser to concentrate the rays of light upon the 
surface under examination. In Manchester, England, where the 
days are so often dark, textile workers adopt various expedients 
to get true color values ; one of these consists in having the artificial 
light pass through specially colored glass. That one should accustom 
himself to the changes of color produced by different kinds of arti- 
ficial light was well shown in one of the author's autopsies made by 
gaslight on a subject of poisoning by battery-fluid: the tissues stained 
with potassium bichromate presented an entirely different appearance 
when examined by daylight the next morning. 

Time and labor will, of course, be saved by making the autopsy 
before the body is dressed for interment, and the undertaker should 
be directed not to embalm it until after the completion of the examina- 



Fig. 2. — Body in a coffin prepared for a post-mortem examination. In this ease the board supporting the body 
is elevated by means of a soap-box. 




Fig. 3.— Post-mortem table for a babe, constructed of chairs and a drawing-board; the marble slab from a wash- 
stand or bureau may be used for the same purpose. 




T3 2 
be - 



GENERAL CONSIDERATIONS g 

tion. The fact that the appearance of the exposed parts is improved 
by the loss of blood and by its gravitation into the larger cavities of 
the body as a result of the post-mortem section may be mentioned 
to him as an argument in favor of the procedure. Fortunately, the 
formalin injecting fluid now generally employed for embalming pur- 
poses does not interfere with the microscopic study of tissues as did 
the arsenical preparation formerly used. Indeed, one of the special 
methods for hardening the brain is based on its previous injection 
with formalin by means of a cannula introduced through the orbit 
or nasal cavities. 

The amount of preparation necessary for an autopsy will depend 
somewhat on whether the examination is to be made (I.) in a private 
house or at an undertaker's establishment, or (II.) in a hospital or 
morgue. 

I. In the former case a table on which to lay the cadaver is rarely 
available, and a substitute must be provided. There are in the market 
several portable operating tables 1 which may be used for this purpose, 
as the one shown in Fig. i. The postmortem may be performed 
while the body lies in the coffin, on the coffin-lid, or, still better, on 
the bottom of the inverted coffin, on the wooden slab usually found 
in the box, or on a door taken from its hinges and placed upon two 
kitchen chairs. The undertaker may have prepared the corpse for 
the autopsy, as seen in Fig. 2. For the body of a child the marble slab 
from the top of a bureau or wash-stand placed on the backs of chairs 
may be used. (Fig. 3.) 

To facilitate the necessary manipulations, the cadaver must lie at 
a proper height. If placed too low, the stooping position required in 
making the autopsy is most fatiguing. A piece of oil-cloth, mackintosh, 
or old carpet should be placed under the table or its substitute, to pre- 
vent soiling the floor. In addition to the articles brought by the opera- 
tor (see page 35), two buckets half filled with lukewarm water, an 
empty basin, and several newspapers should be provided. 

Scrupulous cleanliness in the performance of an autopsy is of the 
greatest importance. The reasons for this are apparent. We owe it 
to our fellow-men to leave no malignant organisms in the place where 
the postmortem was performed. Besides, the pathologist can see bet- 



1 Sherman, American Medicine, October 26, 1901. Illustration from Inter- 
national Clinics, vol. i., Twelfth Series, 1902. 



IO POST-MORTEM EXAMINATIONS 

ter and his sense of touch is finer if the organs, fingers, and rubber 
gloves are not besmeared. 

If the operator be careful not to soil his own person, the surround- 
ing objects will be more likely to escape contamination. For this 
reason, he may accustom himself in private work to make necropsies 
on non-contagious cases with but little protection to his clothing. In 
France the usual dress consists of a hospital blouse, overalls of home- 
spun, an apron reaching to the feet, and a pair of sabots or wooden 
shoes. In our hospitals the regulation duck trousers, shirt-sleeves, bare 
arms, rubber gloves, and an apron are most frequently seen. There 
should be a bountiful supply of water, a basin for the hands, and a 
board on which to arrange the instruments. The parts under exami- 
nation should be cleansed as occasion requires by a stream of water 
squeezed from a sponge, the sponge itself not being permitted to touch 
the tissues. Mucous and serous surfaces should be carefully inspected 
before washing. 

In private work the laity are likely to estimate the skill of the 
pathologist by the neatness displayed in sewing up the body and the 
appearance of the room after the autopsy is completed. The greatest 
care should be exercised that no blood-stains be left behind. Incense 
or cascarilla may be burnt or ground coffee strewn on red-hot coals 
to remove the odor from the apartment, which should then be thor- 
oughly aired. 

II. In a hospital or morgue the facilities for making postmortems 
are much more complete. The room set apart for this purpose should 
be clean, well lighted, and secure against intrusion. The author re- 
members once having seen, much to his annoyance, a number of con- 
valescents in the grounds of a hospital watching the performance of 
an autopsy through an open window. If practicable, the dead-house 
should communicate by an underground passage with all the wards of 
the hospital, and a covered or screened court for the undertaker's wagon 
should also be provided. A well-appointed mortuary room, like the one 
at the Ayer Clinical Laboratory of the Pennsylvania Hospital (Fig. 
4), should have a refrigerator box with scales so arranged that bodies 
can be weighed within it. At the author's suggestion, the Fairbanks 
Scale Company fitted one of their scales to a Ridgeway refrigerator 
for this laboratory (Fig. 5), in such a way that the cadaver could be 
weighed while in the ice-chest and the result noted without opening 
the doors. (For structural plans see Figs. 6, 7, and 8.) The 




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Fig. 6. — Working plans for preparing refrigerator with eight compartments for the storage of 
bodies preparatory to their removal for burial. Front view. 




Fig. 7.— Ground plan for a truck 
a, guide ; b, track. 



Fig. 8.— Cross-section. 



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GENERAL CONSIDERATIONS H 

corpse should be weighed as soon as it is brought into the dead- 
house, as it will usually be found to lose weight after a time. Each 
box should have two doors, one opening into the post-mortem room, 
and the other into a waiting-room on the opposite side, through which 
the body may be viewed by friends and removed by the undertaker. 
This arrangement prevents the transmission of noises and odors. The 
waiting-room ought also to be such that religious services may be 
held in it, if desired. 

The operating table should be strongly built, about seven feet long, 
two feet nine inches high, and three feet six inches wide. The top 
may be slate, soapstone, zinc, or copper ; its surface should slope gently 
towards a central perforated depression connected with a drain and a 
ventilating shaft operated by an electric fan, and should be provided 
with sunken grooves converging towards the centre. (Figs. 9 and 
10.) The drains of the post-mortem room should not connect with 
those of the hospital, but empty directly into the main sewer. An 
ideal though expensive plan would be to sterilize the waste water. A 
scale of feet, inches, and fractional parts of an inch (or of centimetres) 
should be laid off on the top of the table, or, if this be of slate, upon 
a metal rule sunk into it in such a way that no edges are exposed. For 
class instruction, a revolving table is required, upon which by an in- 
genious fulcrum and lever attachment the body can be weighed. An 
extra iron table like those used in the dissecting-room may be provided, 
in case it is desired to conduct two autopsies at once. The making 
of several necropsies simultaneously was discontinued in one Phila- 
delphia hospital owing to the fact that three livers were found in a 
body subsequently exhumed on account of suspected poisoning. Ad- 
ditional tables, upon which to place instruments, scales, plates, and 
other requisites, should also be at hand. 

Ample illumination should be provided, preferably by a northern 
skylight for day and by a combination gas-light and electric-light fixt- 
ure directly over the table (Figs. 11 and 12) for night work. Plenty 
of water, hot and cold, should be supplied by means of an overhead 
spigot with rubber tubing attached, so that by the use of a mixer a 
steady stream of water at any required temperature may at once be 
had wherever desired. 

To support the head there should be a solid block or a rest similar 
to those used by undertakers. This block should be about forty 
centimetres long, twenty centimetres high, ten centimetres broad, and 



12 POST-MORTEM EXAMINATIONS 

hollowed out on top to receive the nape of the neck. For children 
smaller sizes are to be employed. (See Figs. 66, 121, and 163.) 

A board upon which organs may be placed after their removal, 
for convenience in making sections, etc., should also be at hand, as 
the slate slab becomes slippery from exuded fluid and the organs are 
held with difficulty while being incised. It is the custom abroad to 
set a stool upon which instruments are arranged within easy reach of 
the operator over the upper ends of the thighs. To avoid the spatter- 
ing of dripping fluids when opening the cranium, it will be well to 
place a piece of previously moistened horse-blanket or a mop on the 
floor beneath the head. If the operator be subject to rheumatism, he 
should, while making the autopsy, stand on a piece of dry board 
rather than on the cement or tile floor usually found in mortuaries. 
The latticed w^ood flooring found on ships is well adapted to this 
purpose. The lavatories should preferably be the surgical kind ope- 
rated by the feet. All linen, towels, etc., used in the dead-house ought 
to bear some distinguishing mark, and should be put at once into a 
proper disinfectant or sterilized apart from the other linen of the 
hospital. 

A desk for the post-mortem book, a revolving chair, a slop-sink, 
a wash-stand, several cabinets, a work-table supplied with ordinary 
chemicals, a bacteriologic outfit, preservative fluids, and apparatus for 
preparing frozen sections complete the furniture of a well-equipped 
mortuary. The preparation of the latter adds greatly to the interest 
and value of an autopsy by enabling the operator to compare the 
microscopic and macroscopic appearances of a part while it is still 
in a fresh state. The use of ethyl chlorid as the freezing agent, 
where the more elaborate carbon dioxid or ether freezing apparatus is 
not at hand, may sometimes be advisable. 1 A library and a museum 
should be attached to the dead-house when possible. 

1 Cattell, International Medical Magazine, December, 1896. 



CHAPTER II 

ORDER OF EXAMINATION AND POST-MORTEM RECORDS 

Precision, with simplicity of technic, being the key-note for the 
proper performance of an autopsy, the following three rules will im- 
mediately suggest themselves as proper ones to be rigidly observed in 
the making of post-mortem examinations. 

I. Never disturb any part or organ until its position relative to 
adjacent tissues and organs has been accurately determined. 

II. Never unnecessarily remove a part or organ if the proper in- 
spection of remaining parts or organs will thereby be rendered dif- 
ficult or impossible. 

III. When an organ is to be opened in order to examine its cavi- 
ties, walls, or component parts, the requisite incisions should be made 
in such a way as to permit, as far as possible, of the reconstruction 
of the organ in its original shape and condition. 

In the fulfilment of these conditions it is, therefore, best to begin 
by making a topographic examination of the contents of the cavity 
about to be explored. In the case of the trunk, the organs of the 
abdominal cavity are inspected first, those of the thorax next, and 
those of the pericardium last, whereas the removal of the organs and 
their minute description should be made in the reverse order. The 
abdomen should be examined before the thorax is opened, in order 
that the position of the diaphragm and the relative situations of the 
various abdominal organs can be determined before the entrance of 
air into the relaxed thoracic walls has altered the normal relationship, 
before the heart has been emptied of its blood by cutting the abdominal 
veins, and before the escape of blood and other liquids has obscured 
the appearances of the parts under consideration. 

In order that nothing of importance shall be overlooked, the 
pathologist should have a definite plan of survey that he follows at 
every autopsy. The following order of examination is recommended : 

1. Inspection of the exterior of the body. 

2. Topographic exploration of the abdominal cavity. 1 

3. Topographic exploration of the thoracic cavities. 1 

1 The organs are not yet incised nor are their relations markedly disturbed. 

13 



I 4 POST-MORTEM EXAMINATIONS 

4. Pericardium. 

5. Arch of the aorta. 

6. Heart. 1 

7. Lungs, (a) Left, (b) Right. 2 

8. Larynx and trachea ; external examination of the oesophagus. 

9. Omentum, mesentery, and other portions of the peritoneum. 

10. Spleen. 

11. Intestines, except the duodenum. 

12. (a) Left adrenal body and semilunar ganglion, (b) Left kidney, (c) Right 

adrenal body and semilunar ganglion, (d) Right kidney. 

13. Ureters and bladder. 

14. (a) In the male: Prostate gland, spermatic cord, urethra, testicles, etc. (b) 

In the female : Uterus, tubes, ovaries, broad ligaments, urethra, etc. 

15. Duodenum and its ducts. 

16. Stomach and oesophagus. 

17. Liver and gall-bladder. 

18. Pancreas and adjacent fat. 

19. Retroperitoneal glands, the diaphragm, psoas muscle, thoracic duct, thoracic 

and abdominal aortae, vense cavse, abdominal sympathetics, abdominal 
portion of the spermatic duct, etc. 

20. Head, (a) Scalp and skull, (b) Meninges, (c) Encephalon. (d) Eye. 

O) Ear. (f) Nasopharyngeal cavities, (g) Region of neck. 

21. Spinal cord. 

22. Bones, joints, peripheral nerves, arterial trunks of the extremities, muscles, 

tendons, etc. 

23. Portions preserved, and the character of fluid employed. 

24. Microscopic, chemic, bacteriologic, and physiologic examinations. 

As a general rule, the order above suggested will be found con- 
venient and practical. It must, of necessity, be subject to more or less 
variation, depending on the circumstances of the case. For example, 
in a medicolegal necropsy it is often advantageous to examine the seat 
of the suspected fatal lesion at once, and afterwards resume the order 
given above as nearly as possible. Thus, after death by poison the 
abdominal cavity is immediately inspected, while in a case of gunshot 
wound of the head the cephalic cavity is first investigated. The 
finding of anomalies, malformations, adhesions, etc., or the necessity 
of undertaking special lines of investigation may also cause a de- 
parture from the ordinary procedure. Thus, in autopsies on the re- 
mains of those who have died from nervous diseases it is often best 
to remove the brain and cord before opening the body. 

1 While the heart is being examined, time may be saved by having an assistant 
undertake the opening of the skull, as, theoretically, the heart should be exposed 
before the head is opened and the brain inspected before the heart is incised. 

2 The pleural cavities, already superficially examined, are to be most carefully 
inspected after the removal of each lung. 



ORDER OF EXAMINATION ! 5 

Letulle advises that the thoracic and abdominal organs be re- 
moved en masse from the body and first examined from their posterior 
aspect, as follows : x 

(i) Large, or right, and small, or left lower, azygos veins. (2) Thoracic duct 
(dissection). (3) Suprarenal glands (dissection and removal). (4) Ureters (dis- 
section). (5) Kidneys and their pelves (dissection and removal). (6) Thoraco- 
abdominal aorta (opened). (7) Inferior vena cava (opened). (8) Main portion 
of the portal vein and its branches of origin. (9) Common bile-duct and its two 
canals of origin. (10) Pancreas (dissection of posterior surface, tail, and borders). 
(11) Removal of the thoracico-abdominal aorta. (12) Dissection of the oesophagus 
to its point of entrance into the stomach. (13) Organs of mouth and pharynx: 
(a) incision of the pharynx; (b) dissection of the velum palati ; (c) tonsils; (d) 
tongue: (e) sublingual glands. (14) Incision of the oesophagus at its point of 
origin. (15) Epiglottis and larynx (examination and opening). (16) Trachea and 
primitive bronchi. (17) Pulmonary roots (examination). (18) Lymphatic glands 
of the posterior region of the body (deep cervical, posterior mediastinal, diaphrag- 
matic, prelumbar, retrorectal). (19) Cervicothoracic portion of the pneumogastric 



After the posterior examination is completed, the parts are turned 
so that their anterior aspect comes into view. In doing this care is to 
be taken that the attachments are not twisted on their axes. The fol- 
lowing order of examination from the anterior surface is then to be 
adopted : 

(1) Thymus gland (examination and removal). (2) Thyroid gland (dissection 
and removal). (3) Opening of the superior vena cava and its branches of origin. 

(4) Study of the termination of the thoracic duct and the great lymphatic vein. 

(5) Pericardium (inspection and opening of). (6) Examination of the cardiac 
plexus. (7) Dissection of arch of the aorta and the thoracic aorta down to the sev- 
enth costal artery. (8) Pulmonary artery and its extrapulmonary branches (separa- 
tion and opening of). (9) Pulmonary veins, extrapulmonary portion (separation 
and opening of). (10) Hilum of the lung (examination). (11) Examination of the 
exterior of the heart. (12) Removal of the heart. (13) Removal of the lungs. (14) 
Diaphragm (examination). (15) Liver and extrahepatic biliary ducts (examination 
and removal). (16) External examination and separation of spleen, stomach, pan- 
creas, and duodenum. (17) Removal of oesophagus, stomach, pancreas, and duo- 
denum. (18) Exterior examination, dissection, and removal of intestinal canal, 
with the exception of the rectum: (a) small intestine, (b) caecum, (c) vermiform 
appendix, (d) colon, (e) rectum, (f) anus. (19) Examination of the peritoneum: 
(a) mesentery, (b) omentum, and (c) parietal peritoneum; (d) pelvic cavity. (20) 
Urinary apparatus (separation and examination of) : (a) kidneys; (b) ureters; (c) 
bladder; (d) urethra. (21) Genital organs: (a) prostate, vesiculse seminales, vasa 
deferentia, and testicles; (b) oviducts, broad ligaments, ovaries, vulva, vagina, and 
uterus. 

1 This mode of procedure presents greater advantages in a child than in an adult. 



!6 POST-MORTEM EXAMINATIONS 

A lesion found in one portion of the body may indicate the exist- 
ence of pathologic conditions in another perhaps remote part. For 
example, multiple melanotic sarcomata of the liver are frequently 
secondary to a primary growth in the eye; embolism in the brain 
often arises from malignant endocarditis; haetomata of the ears will 
suggest chronic meningoencephalitis, with thickening of the cranial 
meninges; and the presence of miliary tuberculosis should lead to 
an examination of the pulmonary arteries for tuberculous thrombi 
arising from caseous tuberculous glands. Again, particles of coal- 
dust embedded in the hands demand a careful inspection of the lungs 
for anthracosis, while bronzing of the skin will suggest scrutiny of 
the adrenals and of the sympathetic ganglia (Addison's disease). 

If the ascertainment of the cause of death be the object in view, 
the line of inquiry should be based upon a hypothetical or tentative 
diagnosis suggested by the clinical history or special circumstances 
of the case. This may subsequently be corrected, modified, or aban- 
doned as the autopsy proceeds ; but the final diagnosis should, of 
course, not be made until the autopsy has been completed and any 
material requiring subsequent investigation reported upon by those 
undertaking this part of the work. There are cases in which it is 
impossible to state positively the cause of death, even on the completion 
of the autopsy, after a most thorough and painstaking examination. 
In such instances, as in all others, the accuracy of the conclusions 
drawn will depend upon the care exercised in the observation of de- 
tails. Fortunately for those having to do with cases coming under 
the notice of the coroner, sudden death is nearly always attended by 
well-marked pathologic lesions. When no such cause of death is 
found, chemic or early microbic poisoning should be suspected. Any 
epidemic disease, such as smallpox, which is now (1904) so widely 
distributed throughout America, should always be thought of during 
the time of its prevalence, as death therefrom may occur before the 
characteristic rash or symptoms have made their appearance. 

The following characteristics of each organ are to be noted, par- 
ticular attention being given to those structures which are most vitally 
connected with the functional activity of the part. 

1. Situation and relation to other parts. 

2. Size and weight. 

3. Shape, contour, borders, and coverings (capsule, serosa, mucosa, etc.). 

4. Color. 



ORDER OF EXAMINATION T y 

5. Consistency. 

6. Anomalies and malformations (congenital and acquired). 

7. Fractures, dislocations, and lacerations. 

8. Cut surfaces and liquid exuded. 

9. Odor. 

10. New growths. 

11. Other pathologic conditions, taking into account the condition of the vessels 
to and from as well as in the part under consideration. 

i. Situation and Relation to other Parts. — This takes into account 
any departure from the normal position or attachments of the organ. 
There are a number of regional landmarks frequently used; thus, 
in the case of the diaphragm we speak of its height in relation to the 
ribs or the intercostal spaces; of the stomach, as extending so many 
inches above or below the umbilicus; of the heart, in its relation to 
the nipples and the xiphoid cartilage ; and of the cord, as to the verte- 
brae. While it may usually be easy to distinguish from which side an 
organ has been taken when there are no marked changes in its shape, 
the author has found that much time is saved and confusion avoided 
by marking each of the double organs as it is removed from the body, 
— one nick for the left and two nicks for the right-sided organs. 

Plate I, which will be found upon the inside of the front cover, is 
based upon Cunningham's Anatomy, and will be helpful in the prep- 
aration of outline charts of the body for recording the situation and 
extent of lesions discovered at postmortems. The drawing shows 
the normal relations of all the important thoracic and abdominal 
viscera. Those who are unable to draw can place a sheet of thin paper 
over the figure and prepare an outline, which, after being filled in 
according to the exigencies of the case, may be pasted in the notes 
for future reference. One may purchase in England gummed outline 
charts in sheets of the brain and other parts of the body, upon which 
may be sketched in black ink the lesions which it is desired to record. 
Such drawings may then be sent at once to the engraver for reproduc- 
tion in order to illustrate matter intended for publication. 

2. Size and Weight. — For tables of weights and measures of the 
body, see Chapter XXIV. Whenever possible, it is advisable to give 
dimensions in centimetres and weight in grammes; if, however, 
measures and weights are to be used when giving testimony in a court 
of justice, it is well to convert them into inches and pounds, ounces, 
and grains avoirdupois before going on the witness stand. It should 
be remembered that a large organ is not necessarily a heavy one. 



x8 POST-MORTEM EXAMINATIONS 

Atrophy and hypertrophy may be present in the same part, as seen 
in cases of hypertrophic cirrhosis of the liver in which acute yellow 
atrophy has supervened. 

For determining bulk various means are employed besides actual 
measurement. A number of familiar objects at once suggest them- 
selves, which may be used for comparison in describing the size of a 
lesion or part. Most persons have only vague and more or less er- 
roneous notions concerning the dimensions of many common things, 
such as the head of a horse (usually underestimated) or the height 
from the ground of a stationary wash-stand (generally overesti- 
mated). A lesion may appear larger or smaller by being elevated or 
depressed and of a color like or unlike that of the surrounding parts. 
Virchow had, in the old Charite dead-house before its destruction 
by fire, a cabinet containing specimens of various familiar objects, 
such as beans, peas, lentils, barley, etc., with which pathologic lesions 
could be compared. (Plate II.) Later on, recognizing the relation 
of specific gravity to size and weight, he estimated the size by noting 
the quantity of water displaced by the organ when placed in a large 
flask of known capacity. 

3. Shape, Contour, Borders, and Coverings {Capsule, Serosa, 
Mucosa, etc.). — All deviations from the normal in these particulars 
should be noted. It is often advisable to use the name of some 
well-known object in describing the configuration, — e.g., cauliflower 
growth, hobnail liver, etc. As to the external appearance of a solid 
organ, its surface may be smooth, granular, nodular, shrivelled, or 
puckered. Here also we describe the capsules of organs, the serous 
coverings of the various parts, the mucous membrane of the stomach, 
vermiform appendix, etc. The borders of organs that have under- 
gone infiltration are usually rounded and filled out; in degenerations 
they are generally flatter, thinner, and sharper than normal. Thus, 
in fatty infiltration the edges of the liver are rounded, while in cirrhosis 
its margins, often so largely composed of connective tissue as to con- 
tain practically no liver-cells, are sharply defined. The general con- 
tour of the blood-vessels may be markedly changed, as in aneurisms. 

4. Color. — It is most difficult to describe colors or to reproduce 
them satisfactorily. Three-color printing does not give such good 
results as lithography. The best color values are obtained by the 
kromskop, 1 which has a wide field of usefulness not as yet recognized. 

1 Cattell, International Clinics, vol. ii., Tenth Series, 1900. 



2 3 4 5 MILLIMETRES 8 9 1Q 




ORDER OF EXAMINATION T g 

Various shades of red are the most common tints found in the body; 
there is no such thing as pure white, even the conjunctivae being a 
pearl-grayish pink. In pathology the word " pale" means relative 
deficiency of color. Note the color of the organ as soon as possible 
after exposure, as air, light, and water tend to alter it considerably, 
though naturally more or less change brought about by death has 
already occurred. Thus, the pericardium, which during life is trans- 
parent, is at autopsy only translucent. An organ should not be washed 
before its color is described, as water removes part of the coloring 
matter present, acts on the proteids, and modifies the original consist- 
ence of the organ ; these changes may readily be demonstrated by 
placing the thymus gland with the surrounding areolar tissue in run- 
ning water for five minutes. Air oxidizes the blood, so that a bluish 
stain may in a short time change to bright red. In the case of a con- 
gested lung it is well to note its appearance both before and after 
the blood has become oxidized. Certain abdominal organs are fre- 
quently discolored by a greenish slate tint supposed by some to be due 
to the deposition of the iron from the haemoglobin by the hydrogen 
sulphid arising from decomposition. In a case of ammonium hy- 
drate poisoning observed by the author, although the body was well 
preserved, the characteristic discoloration had penetrated the sub- 
stance of the liver to a depth of three-quarters of an inch. Poisons 
often change the color of the blood markedly, and degenerations 
and infiltrations alter the appearance of the various parts affected. For 
a further description of the blood, the reader is referred to page 113. 

5. Consistency. — This is learned only by experience, and is de- 
termined by pinching the organ between the thumb and the index- 
finger and by noticing its behavior when held in the hand. Palpation 
may often be practised with advantage. It should be remembered that 
consistency is affected by the season of the year, by the temperature 
of the cadaver and of its surroundings, by the length of the interval 
between dissolution and the making of the autopsy, by the manner 
of death, by the means used for the preservation of the body, and by 
various other influences. 

6. Anomalies and Malformations (Congenital and Acquired). — 
Each part or organ is subject to its own peculiar anomalies and mal- 
formations, and an entire chapter might readily be written upon the 
various altered conditions, congenital and acquired, revealed by au- 
topsies. Thus, the writer has seen perforation of a typhoid ulcer in 



20 POST-MORTEM EXAMINATIONS 

a Meckel's diverticulum; free calcified bodies in the abdominal cavity; 
peculiar curvatures of the iliac arteries; the left kidney shaped like 
the spleen ; the tip of the vermiform appendix resting near the pyloric 
end of the stomach; an artificial anus made by the rupture of a 
typhoid ulcer; the vermiform appendix in a left femoral hernia and 
the sigmoid flexure in a right inguinal hernia; a fish-bone in the 
omentum, etc. 

7. Fractures, Dislocations, and Lacerations. — Every degree of 
injury may be represented. It should be remembered that from the 
external appearances alone it is not possible to state definitely the 
extent of the internal lesions. A heavy wagon may run over a child 
without rupturing the skin, though the internal organs may be lace- 
rated and torn to a remarkable extent. The writer had an instructive 
case where a man struck a lamp-post' with a push-cart, the handle of 
which entered his hepatic region; the external injury was not larger 
than a silver dollar, but hemorrhage from laceration of the liver 
finally caused death. Injuries are especially apt to be overlooked in 
those parts which are covered with hair. 

8. Cut Surfaces and Liquid exuded. — When an organ is incised, 
describe first that which is most striking, as, for example, the presence 
of a hydatid cyst that is exposed on section of the spleen. Note the 
color of the exposed surface; whether it is smooth or granular; the 
amount, character, and chemic reaction of the fluid that is spontane- 
ously exuded or is obtained by scraping with a knife; and the con- 
dition of the blood-vessels, especially as to atheroma and thrombosis. 
Numerous incisions may lead to the discovery of new lesions or afford 
an opportunity of studying the morbid process in its various stages. 

Under the term " liquid exuded" are included not only blood, 
transudates, and exudates that follow incision of the part, but also 
any fluid that may be contained in the cavity of a hollow organ or in a 
cyst present, and the juice that appears on scraping or squeezing. 

(Edema of an organ may be detected by squeezing it. In the 
lungs a frothy oedema shows the absence of a pneumonic infiltration. 
Surfaces should be scraped and the material thus obtained examined 
with the microscope. 

In describing cavities pay especial attention to the lining mem- 
branes, noting their color, lustre, smoothness or roughness, and the 
presence of any adhesions; also the quantity, color, consistence, odor, 
and reaction of their contents and any sediments found therein. 



ORDER OF EXAMINATION 2I 

9. Odor. — It is safe to predict that more and more attention will 
be given to the significance of .odor. The organ of smell is imperfectly 
developed, and varies greatly in different individuals and in the same 
individual at different times. The peculiar odor that accompanies the 
growth of certain bacteria, such as the Bacillus coll communis, is well 
known. Smallpox, measles, cancerous ulcerations, and gangrene of 
the lung have their peculiar stenches. We may also mention the 
odor of acetone in diabetes, the pus-like odor in leucocythsemia, the 
butyric-acid-like or alcoholic odor from the brains of those who have 
drunk heavily before death, the uraemic odor, the odor in cases of 
carbolic or hydrocyanic acid poisoning, etc. The following poisons 
may also be recognized by their odor : opium, methylic alcohol, paral- 
dehyde, chloroform, ether, formalin, creosote, iodin, iodoform, bro- 
min, bromoform, chlorin, phosphorus, nitrobenzol, ethereal oils, amyl 
nitrite, ammonia, tellurium salts, etc. Fischer and Pentzold x state 
that the one five-millionth part of a gramme of chlorphenol or of 
mercaptan may be recognized by the sense of smell. For another 
illustration, see the action of the Penicillium brevicaiile on arsenical 
preparations, p. 331. Too often a case of apoplexy is taken to a police- 
station and the diagnosis is there recorded as one of alcoholism, simply 
because the odor of alcohol is found on the person arrested. 

10. Xczv' Grozvths. — It is important to determine at once the pres- 
ence of tumors, cysts, worms, etc., in a part, as subsequent manipula- 
tions may have to be markedly altered by their discovery. 

n. Pathologic Conditions. — Every death may be attributed to one 
or more of the three following proximate causes : I. Interference with 
respiration, called asphyxia or apncea ; II. Interference with the heart's 
action, called syncope ; and III. Interference with the nervous system, 
called coma or shock. The number of distinct diseases capable of 
producing death is limited, as will be seen by reference to the Bertillon 
classification of the causes of death given in Chapter XXVIII., the list 
not being nearly so large as one might expect without due considera- 
tion of this subject. There is also a distinct repetition of morbid 
processes in the different diseases and in the different parts. It is also 
well to remember that the histologic structure of an organ often at 
once gives information as to the lesions which will possibly be present 
in an affected part. In making a postmortem the diseases from which 

1 Jr. Amer. Med. Assoc, April 23, 1904. 



22 POST-MORTEM EXAMINATIONS 

a person is liable to die and the lesions which may be found in any 
individual part or organ should always be carefully considered. Bear- 
ing this point in mind, considerable care has been taken in the prep- 
aration of the index in order to aid the reader in reaching a proper 
diagnosis by refreshing his memory as to the possible diseases or dis- 
turbances that may take place in the part or organ under study. By ex- 
clusion, the character of a lesion under observation may often at once 
be reduced to two or three possibilities, the final diagnosis being 
reached, in many cases, only by microscopic study. The index will 
also be found of use as suggestive in the preparation for an examina- 
tion in pathology before a State Board or elsewhere. 

Note Taking. — Relying upon one's memory for records is a 
treacherous practice, and appearances which seem to be of no impor- 
tance while the organ is before you are often of value to others who 
for various reasons may be called upon to read the protocol of the 
autopsy, but who have not had the opportunity of examining the parts 
in which they are interested. It is important, especially in medicolegal 
cases, to write " examined" or " normal" * after the number referring 
to the part under study, where no lesion exists, as this shows that an 
actual examination of this portion of the body has been made. 

The notes should always be dictated in a distinct tone of voice 
and in easily understood language while the autopsy is in progress, and 
should consist exclusively of descriptions of the conditions then and 
there observed. Numbers and doubtful words should be at once re- 
peated by the scribe, as an additional safeguard against error. Like 
the anaesthetist at an operation, the amanuensis should pay strict at- 
tention to the work assigned him. Names of diseases should be 
omitted in the notes themselves, but are to be inserted under the head- 
ing of " Pathologic Diagnosis" at the head of the report. The record 
of morbid changes present ought to be full, clear, and exact, so that 
from it alone the pathologic lesions can be inferred by another pa- 



1 Objection to the use of the word "normal" may properly be raised, for what 
one person may consider normal another would class as abnormal, while its use by 
an inexperienced person might lead to the omission of certain data which might be 
of importance in the future. It is, therefore, well to describe the part in detail. This 
will not only impress upon the obducent the normal appearances, but also lead him 
to make a more critical examination than he otherwise would be likely to do. The 
comparison of one organ with its fellow or of one part of the organ with another is 
often of value in this connection. 



NOTE TAKING 23 

thologist as well as by the one who performed the necropsy. If the 
post-mortem record is rewritten, any descriptions given during the 
superficial examination may be combined with the detailed account of 
the parts removed from the cavity examined, thus permitting of the 
omission of any possible repetitions. One well-worded description 
of an autopsy dictated to a reliable amanuensis during the progress of 
the work is of much more value than scores written from memory 
after their completion. Drawings, photographs, skiagraphs, krom- 
skopic pictures, casts, microscopic slides, properly mounted museum 
specimens, and cultures of micro-organisms make valuable additions 
to a well-written account of a postmortem. 

The liability to mistake, of which every day furnishes examples, is 
nowhere more forcibly exemplified than in the performance of post- 
mortems and the description of the appearances of the parts examined. 
What serious errors may result from poor writing or through mis- 
understanding, as in conversations over the telephone, is shown by 
the following illustrations. A pathologist communicated by telephone 
to the secretary of a surgeon the diagnosis of adenocarcinoma. The 
report received by the surgeon was to the effect that the patient " had 
no" carcinoma. 1 Often the word " atypical" is understood in the sense 
of "a typical." There is also an amusing side to this subject. In 
abstracting an article by Banti for the International Medical Magazine 
in 1895, tne author wrote of the bacillus there described as being 4 p. 
long by 1 ft broad. The style of the office where the magazine was 
printed was to spell out numbers, and it appeared in the galley proof 
that " The bacilli are four feet long by one foot broad" ! 

Post-mortem records may be kept in a book specially prepared for 
that purpose, or on sheets to be filed away with the clinical history of 
the case under consideration. To every autopsy performed by myself 
I give a specific number, and lately have preserved my records on sheets 
kept in a flat-opening note cover-book, until they are ready to be filed 
away and indexed in properly-made manila covers. The interchange- 
able sheets in the note-book measure seven by eight and one-half 
inches. By means of an ingenious clasp opening in the centre, one 
end being fixed and the other movable, the leaves are held in place by 
passing the clasp through two small circular openings on the left-hand 
side of the page. When the clasps are closed, the leaves can be turned 



1 Amer. Med., Dec. 5, 1903. 



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like a book; when open, one or more sheets may readily be removed 
or others inserted. This method I find superior to the practice of 
keeping the records in special books or on the large index cards which 
are used by many physicians in preserving their private case records. 1 

In post-mortem books prepared for hospital records it is advan- 
tageous to have some data printed at the top of each page if the 
book be a large one or at the top of the left-hand page alone if the 
book be less than ten by fifteen inches, so as to afford ample room for 
notes. In my service at the Pennsylvania Hospital I used the form 
given on the opposite page. 

The routine order of examination to be employed in the making of 
the autopsy, as given on p. 16, may then follow, or a card showing 
this order may be displayed in such a manner as readily to be seen by 
the one making the autopsy and the person to whom the notes are 
being dictated. Figures corresponding to the numbers of the divisions 
in the list may then be placed just before the notes describing the 
lesions to be sought for in the parts under examination. 

Many writers advise the use of more or less elaborate printed de- 
scriptions of the various anatomic regions and organs, with blank 
spaces to be filled in at the time of making the autopsy. Printed books 
and forms for this purpose are to be found on the market, especially 
in England. This method of keeping notes has not in my hands 
yielded as satisfactory results as the one just described. I give, how- 
ever, the following example of a post-mortem record, which was pre- 
pared in 1890 by Dr. Formad and myself and was in use for a number 
of years at the Philadelphia Hospital. The opposite (right-hand) page 
contained no printed matter, and could be used for more extensive 
descriptions or for the dictated record of the entire autopsy. 

1 International Clinics, vol. iv.. Eleventh Series, 1902. 



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CHAPTER III 

POST-MORTEM INSTRUMENTS AND HOW TO USE THEM 

Various combinations of post-mortem instruments are found in the 
sets catalogued by dealers, but these, except for the systematic work 
possible only in hospitals and morgues, are more luxurious than neces- 
sary. The former wooden box with its plush lining is an abomination, 
owing to the impossibility of keeping it in a cleanly condition. The 
metal box is satisfactory, and one should be employed which can 
occasionally be sterilized by heat in its entirety. The ends of the box 
should be rounded so as to prevent any sharp edges from injuring the 
hands of the operator. If a box be used, all instruments should be 
thoroughly disinfected and returned to their proper places after each 
postmortem. It is annoying to take such a box to the place where 
the postmortem is to be held and then to discover the very instrument 
wanted to be missing. The instruments that are really indispensable 
for the proper performance of an autopsy are very few in number, 
as a complete examination may be performed in case of an emergency 
with a penknife and an ordinary wood-saw. Of course, in this field, 
as in surgery, ample opportunity has been offered for the exercise of 
mechanical ingenuity, and many instruments have been devised for 
facilitating post-mortem work that save much time and render greater 
neatness and exactitude possible. 

The following list contains the instruments, apparatus, and chemi- 
cals most commonly used in the performance of an autopsy. 

Knives. — Section- or Cartilage-Knives. — These should be made 
very strong, with a broad back, blunt rounded ends, and a bulge or 
belly at the outer third (Fig. 13), and should be narrower at the 
attachment of the blade to the handle. For general purposes the 
length of the entire knife should be from seven to seven and a half 
inches (about eighteen centimetres), the handle measuring about four 
inches. The Germans use knives even as long as eleven inches 
(twenty-eight centimetres). A separate rounded expansion for the 
index-finger found on the back of some section-knives is unnecessary 
(Fig. 14). The sharp-pointed knife should emphatically be con- 
demned (Fig. 15). When the knives are sent to be sharpened, the 
28 



Fig. 15.— Section- or cartilage-knife, with rounded end. (One-half natural size.) 




Fig. 14. — Cartilage-knife with projection on back upon which the index-finger rests when making incisions. 
(.Two-thirds natural size.) 




Fig. 15. — Post-mortem knife with faulty point and without proper belly. (Two-thirds natural size.) 



Hli'iiiijiii'l ij ji |nriiiii:iii|iiii|iiiiiiii! 

I 2. 3 4- 5 (7 7 8 9 10 II 12 13 14 15 "' 



Fig. 16. — Coplin's brain-knife marked in centimetres on one side and in inches on the other. (Reduced.) 




Fig. 17.— Bread-knife, useful in incising large organs, as the brain, the liver, etc. It comes in two 
forms, — with both sides meeting at the cutting edge like an ordinary knife, or with one side perpendicu- 
lar and the other slanting for about three-eighths of an inch above the sharp edge, as shown near the 
handle in the illustration. (One-third natural size.) 




Fig. 19.— Pick's myelotome. This little instrument is useful for severing the spinal cord in the removal 
of the brain. (One-half natural size.) 




Fig. 20. — i, desirable form of forceps with spring; 2, saw with rounded end ; 3 and 4, proper shapes of needles; 5, 
small saw with rounded end; 6, spring forceps; 7, box-jointed tenaculum forceps; 8, solid-headed hammer; 9, steel 
tape measure; 10, combined hone and strop ; n, scalpel with rounded hard-wood handle. (Reduced about one-half.) 



Fig. 2i.— A very desirable saw for post-mortem work ; it is solidly constructed, and the teeth on the 
curved end are useful for sawing out the angles in the removal of the skullcap by the angular method. 
I Slightly less than one-half natural size.) 




Fig. 22. — Butcher's saw, very useful for quick work in opening the calvarium. 
(.One-quarter natural size.) 




Fig. 23. — Hey's (Pare's) saw. (Two-thirds natural size.) 



Fig. 2.x. — Metacarpal saw. (Slightly less than two-thirds natural size.) 




Fig. 25.— Luer's double rhachiotome. This instrument is held in the right hand and steadied with 
the left by means of the handle attached to the fixed blade, the other blade being movable by clamps, 
so that the distance between the parallel blades may be varied at the will of the operator. 



POST-MORTEM INSTRUMENTS AND THEIR USE 29 

instrument-maker should be cautioned not to grind them to a point. 
Scalpels, such as are used in dissecting. Those made of a single piece 
— i.e., without wooden, bone, or ivory handles — are to be preferred. 
The brain-knife (Fig. 96) should have a thin blade about ten inches 
(twenty-five centimetres) long, one and a half inches (four centi- 
metres) broad, and blunt at the end like a table-knife. This instru- 
ment may also be used for incising the large organs and in opening 
the cavities of the heart. The brain-knife may be marked in the form 
of a rule and thus serve a double purpose (Fig. 16). An amputation- 
knife may be employed in place of a brain-knife, or in removing the 
brain through a trephine opening made in the skull. A Waring bread- 
knife (Fig. 17), which also does good work, may be used for incis- 
ing the larger organs. A Valentine knife (Fig. 18), which has two 
parallel blades adjustable by screws to keep them the desired distance 
apart in order to cut at will thick or thin sections, is now rarely seen, 
but was much employed before the freezing microtome came into com- 
mon use. Pick's myelotome (Fig. 19) is an instrument with a short 
blade bent nearly at right angles to the shaft, for cutting the spinal 
cord squarely across instead of in an oblique direction. A curved 
probe-pointed bistoury is used in cutting the dura mater, spinal cord, 
etc. A razor was formerly included in all lists of post-mortem instru- 
ments, but is now discarded. 

Saws. — The saw should possess a strong blade solidly attached 
to the handle (Fig. 21), as the two-piece jointed ones, kept in place 
by a screw, are very liable to become loosened. (Fig. 20, 2 and 5.) 
A butcher's meat-saw, which is arranged like a scroll-saw (Fig. 22) 
with its teeth pointing towards the front, its cutting surface measur- 
ing from ten to fourteen inches (twenty-five to thirty centimetres) 
for an adult and six inches (fifteen centimetres) for a babe, or a 
large cross-cut carpenter's saw, does the quickest work in removing 
the calvaria. Hey's saw (Fig. 23) is useful in sawing the angles 
when opening the skull. A metacarpal sazv (Fig. 24) is often of 
sen-ice, especially in examining the femur of a babe for the detection 
of syphilitic osteochondritis. Liter's double rhachiotome (Fig. 25), 
employed for opening the spinal column, consists of two parallel saws 
with curved blades, the distance between which can be regulated 
by screws, and a very firm handle with a strong central support. 
Various forms of dental and trephining engines, usually driven by 
electricity, have recently been introduced and are useful in saving time 



3Q 



POST-MORTEM EXAMINATIONS 



and labor. Among such engines may be mentioned those of Cryer 1 
(Fig. 26), de Vilbiss, Wright, etc. These instruments are high-priced 




Fig. 26.— Cryer's electrical surgical engine for cutting bone. A, spiral osteotome, with guard, for 
removing section of skull ; B, spiral osteotome ; C, trephine ; D, guard for osteotome ; E, electric motor ; 
F, crank for hand propulsion ; G, driving wheel for hand propulsion. 

(from one hundred to three hundred dollars), on account of the in- 
frequent demand for them. Hand-driven instruments may be pur- 
chased for twenty-five dollars and upward. 



1 Medical News, January 30, 1897. 




. -^2. — Proper form of costotome ; the handles do not meet by one-quarter of an inch and the ends 
are not pointed, but rounded. (One-half natural size.) 




Fig. 33.— Improper form of costotome, with pointed blades and a catch, the handles meeting when the 
instrument is closed. (One-half natural size.) 




Fig. 34.— Steel hammer with proper handle. (One-half natural size.) 



m. 






m 



$m 



i^V:^ 




Fig. 36. — Curved chisel, 
used for the same purposes 
as Fig. 35. (One-half natural 
size.) 



Fig. 35. — Solid steel side 
chisel for breaking through any 
unsavved portions of bone in re- 
moving the calvarium. The 
pointed end is used as a pry and 
retractor for pulling out the 
sawed-off poition of the skull. 
(One-half natural size.) 



-;;;'! 



Fig. 37.— Brunetti's left curved 
spinal chisel, of use in opening the 
vertebrae. (One-half natural size.) 




Fig. 38. — Forceps. 




Fig. 39. — Forceps. 



Fig. 40.— Straight grooved director. (One-half natural size.) 



Fig. 41.— Satterthwaites calvarium clamp, closed and in use. 




Fig. 42.— Iron clamp to be applied to the skull before the removal of the brain ; especially- 
used in dissecting-rooms. 





Fig. 43. — Bigelow clamp for holding the 
head in the removal of the brain. 



Fig. 44. — Folding iron head-rest. 



POST-MORTEM INSTRUMENTS AND THEIR USE <$I 

Scissors. — One pair of scissors should be large and strong, with 
long handles and short, stout blades (Fig. 27) ; the other pair should 
have rounded ends with bent handles (Fig-. 28). A pair with separa- 
ble blades is frequently useful (Fig. 29). The cnterotome is a scissors 
with one short and one long blade (Fig. 30), the latter being blunt 
and curved on itself at the end. Be sure that there is no sharp-pointed 
end, as this is the form usually supplied (Fig. 31). The costotome 
(Fig. 32) is an expensive instrument, with short, thick blades, the 
under one being curved and having a strong spring between the 
handles. Dangerous blood-blisters are sometimes produced by pinch- 
ing the skin with the ends of the handles, which usually meet and 
fasten with a catch (Fig. 33). The ends should not meet and there 
is no necessity for the catch. 

Hammers. — The most useful hammer is made of solid steel (Figs. 
20, 8, and 34). One end of the head or striking portion is cuneiform, 
and there may be a hook on the end of the handle which is of service in 
springing off the calvarium. Lead filling in a hammer muffles the sound 
of its impact and prevents rebounding. A wooden mallet is preferred 
by some pathologists. 

Chisels. — There are chisels of various patterns devised for open- 
ing different regions. The straight chisel is the most serviceable, as it 
can be used in an}- region. The T-shaped chisel is also generally useful ; 
it has one arm placed perpendicular to the other, and the arm which 
serves as a handle has one sharp and one blunt end so that it can be 
hammered upon. The chief use of the T-shaped chisel is in springing 
off the calvarium and in elevating the periosteum from it. Guarded, 
hatchet-shaped, and other chisels (Figs. 35 and 36) and spinal 
chisels (Fig. 37) are useful in opening the spinal canal, and a chisel 
with a guard about half an inch, or 1.25 centimetres, from the edge 
will not injure the brain while springing off the calvarium from the 
dura mater. The raspatory of Chiara has a broad, spoon-shaped end, 
four centimetres wide, with which the periosteum from a large surface 
can easily be removed; the other end is of the shape of a lance, one 
inch (2.5 centimetres) long, and is used for deep separation. 

Forceps. — Dissecting forceps are indispensable when it is neces- 
sary to trace small structures; pointed, straight and curved forceps 
are the forms in use. (Fig. 20, 1 and 6.) Bone-forceps, large and 
strong and with rough handles, are necessary. One blade is blunt, so 
that it can be shoved against soft tissues without injuring them, as in 



32 



POST-MORTEM EXAMINATIONS 



cutting the ribs. Lioh-forceps of special type may be used when re- 
moving the bodies of the vertebrae. Dura-tongs, for pulling the dura 
mater away from the calvarium when it is adherent, may save the 
fingers from being injured by the bone. Other forms of strong for- 
ceps are seen in Figs. 38 and 39. 

Grooved (Fig. 40) and curved directors are frequently of use. 

Chain hooks and a tenaculum may be employed, but they are 
dangerous instruments. Hooked retractors are more desirable than 
a tenaculum or chain hooks. 

Various Instruments. — A metal catheter and several flexible 
catheters, all of size number 8, may be needed for withdrawing urine. 
A blow-pipe with a stop or valve, a trocar and cannula, probes, some 
of which have eyes, and some form of injecting syringe are also 
useful. A vise is serviceable in firmly holding bone preparations in 
course of dissection, and in fixing a saw that is being sharpened. A 
skull clamp is considered by some to be of use in removing the calva- 




*jr.j.i...i.T.i.T.Tjajuei 



Fig. 46. — Steel measuring stick marked in centimetres. (Reduced.) 



rium (Figs. 41, 42, and 43). Iron tripods and other special devices 
for holding the head are shown in Figs. 44 and 45. 

Weights and measures of various kinds are frequently found to be 
indispensable. These should include scales, a steel tape measure (Fig. 
20, 9), graduated calipers, graduated glass cones, glass balls, and grad- 
uated measuring vessels of glass. The scales should have a capacity of 
twenty pounds, or ten kilogrammes, and be supplied with weights from 
a gramme upward. They are needed in weighing organs: The steel 
tape measure and the two-feet rule are marked both in centimetres 
and in inches. Graduated calipers or a measuring stick (Fig. 46) may 
be used in determining diameters. Fig. 47 represents an instrument 



u 




FlG. ^5. — Cornell folding clamp for the secure holding of the head in the removal of the calvariun 
(Specifications for the making will be sent upon application to the author.) 




Metal pocket-case of instrument- for finer dissection; very easily Sterilized. 
'About one-hair reduction.) 




^\\\\ 






Fig. 51.— Various ways of wrapping linen twine, cut of proper length and ready for use. 




-Fc. "s leather p< 



holding the instruments usually employed in making ; 
(One-half natural size. ) 



\ 







POST-MORTEM INSTRUMENTS AND THEIR USE 



33 



known as a raspatory. A metal pocket-case for instruments is shown 
in Fig. 48. Graduated wooden cones (Fig. 49) and glass balls (Fig. 
50) are serviceable for measuring orifices and canals. Graduated 
measuring vessels of glass are desirable. The larger vessels should 
be marked at every hundred cubic, centimetres up to one or two litres, 
and the smaller for every two cubic centimetres up to a hundred. A 
stomach-pump is especially useful in withdrawing fluids from cavi- 
ties. A urino meter is often of use. Ladles with a lip or spout, made 
of enamelled or agate ware, and with a capacity of half a pint, or two 




Fig. 47.— Raspatory. (Reduced.) 

hundred and fifty cubic centimetres, are needed in dipping fluid from 
cavities. A whetstone is useful, especially the form with a handle and 
a leather strop on the back of the stone. (Fig. 20, 10. ) A magnifying- 
glass that enlarges at least ten diameters should be in the hands of 
every one making postmortems. 

Other Supplies. — Enamelled trays or basins are useful for re- 
ceiving removed organs, and the basins are also required in cleansing 
the hands and instruments. Blocks of zvood are needed to support 
the body. Metal supports are unwieldy and scratch the table. The 
blocks should be made of very hard wood, as of ebony, were it not 
for the cost, it being most difficult to secure boxwood of the proper 
size. Some of these should be prismatic in form, others excavated 
to fit under the neck during removal of the brain. All wooden utensils 
should be finished with oil so as to be non-absorbent. Earthenware 
plates or zvooden boards are useful during the dissection of organs. 
Needles (Fig. 20, 5 and 4) and coarse ftax thread or Hue twine are 
needed in closing incisions made through the skin. The thread is also 
required in ligating the intestines before removing them. Sponges are 
a necessity readily procured, and should always be moist when in use. 
Pins are useful in fixing small structures in course of dissection. Spe- 
cial tables of zinc-covered wood, slate, iron, or glass are desirable in a 
pathologic department. Rotating tables are convenient, but weighing 
tables are expensive. The table should be constructed so as to carry off 
all fluids into a receptacle provided for them. 

3 



» 4 POST-MORTEM EXAMINATIONS 

Rubber gloves that reach well up the wrist and finger-cots afford 
protection to the pathologist, particularly in cases where the danger 
of infection is great The gloves are more readily put on and are 
preserved by dusting them freely with ground soapstone kept in a 
dusting bottle. Quart museum jars are useful for holding specimens 
to be preserved, and two-ounce, wide-mouth bottles, for microscopic 
specimens. A clean glass bottle with a glass stopper and sealing-zvax 
to keep it closed are needed to receive the contents of the stomach in 
a case of poisoning. Bromin in a strong bottle with a ground-glass 
stopper that fits well serves a good purpose in disinfecting fresh 
wounds. Formaldehyde and distilled water should always be at hand. 

Pails are needed as containers for water and to receive fluid re- 
moved from the body. Cotton wool, sawdust, or tozv placed in the 
large cavities of the body before they are closed prevents the escape of 
fluid from them. An amusing story is told of a Philadelphia professor 
of pathology whose assistant used a self-raising buckwheat flour for 
the purpose ; the formation of gas was so great that an explosion took 
place in the night. Plaster of Paris and sand serve a similar purpose in 
the cranial cavity. Disinfectants and deodorants should not be for- 
gotten, as it is desirable to destroy or neutralize odors emanating from 
the body, and to disinfect and deodorize the hands of the pathologist 
after the examination has been completed. Bellozvs are occasionally 
useful in inflating viscera, as the lungs or stomach. A hand-bag which 
can be cleansed is often required for carrying instruments. 

The chemic, bacteriologic, and microscopic supplies required in the 
work of the pathologist at the postmortem are red and blue litmus 
paper, turmeric paper, Lugol's solution, solution of sulphid of ammo- 
nium for detection of free iron derived from bile pigment, as in perni- 
cious anaemia, Gabbett's solution, carbol-fuchsin, Loeffler's alkaline 
blue, absolute and commercial alcohol, ethyl chlorid or methyl chlorid, 
culture-tubes containing blood-serum, agar, and gelatin (bouillon is 
troublesome to carry), an alcohol-lamp, glass slides and covers for 
microscopic specimens, filter-papers three or four inches in diameter, 
an old scalpel which can be heated, a platinum wire three inches (or 
eight centimetres) long, set in a solid glass rod six inches (or fifteen 
centimetres) long, for making cultures (called an ose), 1 a microscope, 

1 Wetherill has recently suggested the use of an electric ose, the platinum wire 
being connected to a hand-battery of sufficient strength to cause the metal to glow 
when the current is turned on. 



POST-MORTEM INSTRUMENTS AND THEIR USE 

a freezing microtome, and easy access to an incubator. A Paquelin 
thermocauter}- or one of the simpler forms now so commonly used 
for wood burning is very useful for bacteriologic purposes. 

In my own experience it has been found desirable or convenient 
to discard one instrument after another until now my satchel for 
private work weighs with its contents but ten pounds, and con- 
tains the following articles: two section-knives in good condition; 
a scalpel; a pair of medium-sized, strong scissors; a pair of bone- 
forceps; a dissecting forceps; a saw; an enterotome; a hammer 
with a hook on its handle; a pelvimeter; a new rubber catheter; 
gummed labels; various kinds of litmus paper; sealing-wax; a 
dissecting-apron and sleeves ; a pair of rubber gloves, with plenty of 
ground soapstone in an iodoform dusting bottle; finger-stalls; a 
piece of thin rubber sheeting forty-five by thirty inches; a piece of 
oiled silk, or a rubber bag (sixteen by ten by four inches) from which 
fluid will not escape; two medium-sized bath-sponges; a quart 
museum jar graduated into ounces or cubic centimetres, into which 
some of the smaller articles are placed and which can be used for the 
removal of gross specimens later, if desired; a large needle and flax 
twine, cut and wrapped (Fig. 51) into three lengths, for sewing the 
body with single thread (forty-five inches), for sewing the head 
(twenty-five inches), and for tying the intestines (ten inches) ; some 
bromin in a strong bottle with a well-fitting ground-glass stopper: 
two per cent, iodoform celloidin solution ; a small roll of cotton ; four 
two-ounce, wide-mouth bottles for microscopic specimens, one of 
which should be filled with seventy per cent, alcohol, one with ten per 
cent. formalin, one with Miiller's fluid, and the fourth with a saturated 
solution of mercuric bichlorid ; two ounces of creolin ; a cake of one 
per cent, bichlorid of mercury soap ; an ose ; an alcohol-lamp ; several 
culture-tubes properly packed; incense powders; matches; pins, 
safety and ordinary; a steel tape-measure marked in inches and centi- 
metres; a hand lens magnifying not less than ten diameters; spring 
scales weighing up to fifteen pounds; whetstone; and last, but not 
least, a note-book and several pencils, one of which will write on glass. 
To this list may be added other articles as the necessities of the case 
may demand. 

For the private use of the general practitioner, a large section- 
knife, a scalpel, an enterotome, a saw, a chisel, a mallet, a pair of 
scissors, and a large needle may be purchased for about five dollars. 



. () POST-MORTEM EXAMINATIONS 

Those should be kept rolled up in a piece of chamois-skin, preferably 
made with pockets into which the instruments fit, and if the latter be 
put away clean a iter use they are always ready for service; or a 
leather ease | Fig. 52 I may be employed. 

The proper handling of post-mortem instruments is not acquired 
in a day, and the beginner will find that experience teaches many les- 
sons which are not likely to be forgotten. A well-ground, keen-edged 
knife is a great desideratum, the advantage of a dull knife being 
-imply that it is less likely to injure a beginner or careless operator and 
to disfigure the exposed portions of the body. 1 

In opening the body free incisions should be made by an easy, 
untrammelled movement, executed by the muscles of the shoulder 
rather than by those of the arm or hand. It is essential that the knife 
be grasped firmly (Fig. 53), and not held like a pen, as is a scalpel in 
the act of dissecting. Virchow says that the knife should be held in the 
whole hand, so that when the arm is stretched out the blade extends 
with it. The fingers and hands are fixed, if not absolutely, at least 
relatively, and the motion is executed with the whole arm, so that the 
movement is principally in the shoulder- joint and secondarily in the 
elbow-joint. Thus the whole strength of the arm and shoulder muscles 
1- brought into play, and long, smooth incisions, so essential to proper 
inspection, are made. In cutting, pressure should be uniform, and the 
greater the pressure the quicker will the knife pass through the tis- 
sues. A clean cut made in the wrong place does less harm than a 
ragged one in the right place (Virchow). The portion of the blade 
near the handle should be used for work which dulls a knife, as cutting 
the ribs. This also applies to scissors, the part near the pivot being em- 
ployed in all cases in which considerable force is required. When the 
knife is held as shown in Figs. 58 or 60, but preferably as in Fig. 60, 
..ie operator is sure to have a firm grasp of the knife-handle, so that 
there will be little likelihood of a dangerous slip. The actual cutting is 
properly and mainly done with the belly of the knife about one inch 
fr<.m it- end, for which reason this part of the blade is always the thick- 
The direction of the incision should invariably be from the oper- 
ator, especial care being taken not to wound the left hand, and from 
those portions of the subject in which disfigurement would be most 

1 The method of holding and using the instruments will be seen illustrated by 
reference to the pages treating of the examination of the various organs. 



POST-MORTEM INSTRUMENTS AND THEIR USE 37 

likely to be noticed. Care must also be taken not to injure the assist- 
ants or those standing near. When the resistance of a tissue is un- 
expectedly overcome, the knife will sometimes travel a considerable 
distance before it can be stopped by an effort of the will. 

The blade of the knife must be kept free from blood by frequent 
washing. This is especially necessary when incising organs, as the 
brain, in which incisions are made with much more satisfaction if the 
knife-blade be previously moistened. A pointed knife may be used for 
the removal of the tongue and the larynx, and a scalpel for fine dis- 
section, as in tracing the spermatic or thoracic duct. 



CHAPTER IV 

THE (.ARE OF THE HANDS AND THE TREATMENT OF POST-MORTEM 

WOUNDS 

Before beginning the autopsy, especially in a purulent case, the 
pathologist should carefully examine his hands; if these be not in 
good condition, the notes may be dictated by him while some one 
else is doing the actual cutting. All rings should be removed and 
the finger-nails cut close, except possibly those of the thumb and 
index-finger of one hand, which may be left slightly protruding in 
order to grasp certain parts, as the capsule of the kidney, to facilitate 
its removal, — a feat often difficult of accomplishment without the use 
of an instrument, such as a knife, when rubber gloves are used. 

Abrasions of the skin of the hands and forearms may be detected 
by the application of a ten per cent, solution of glacial acetic acid, 
which will at once reveal the location of such lesions by the smarting 
sensation that ensues. Slight wounds on the hands may be protected 
before beginning the necropsy by placing a small piece of absorbent 
cotton upon them and then applying the ordinary thick celloidin used 
in bacteriologic work, or the two per cent, iodoform celloidin already 
referred to. Varnish such as is used to coat pictures, liquid gutta- 
percha, or liquid court-plaster may also be employed for this purpose. 

It was once the custom for pathologists before starting work upon 
the body to anoint their hands with some antiseptic salve, such as 
vaselin containing boric acid, ten grains to the ounce, a ten per cent. 
carbolic acid ointment, or a solution of the balsam of Peru. If these 
be used, they should be renewed several times during the progress of 
the autopsy. It is, however, doubtful whether the advantages gained 
by their employment are not more than offset by the fact that the 
hold upon the instruments is thereby rendered less secure. This can 
to a certain extent be avoided by fully anointing only the left hand 
i the one which handles the tissues) and the back of the right (the 
hand that holds the instruments), thus limiting the application of the 
protective to those parts through which infection usually takes place 
when no mechanical injury to the hands is inflicted. Frequent wash- 
ing of the hands in clean water is regarded by many as decidedly 
38 



CARE OF THE HANDS 39 

better. Of course, when digital investigations are necessary, as in 
exploring fistulous tracts, examining the vagina and os, and in certain 
kinds of peritonitis, antiseptic unguents are desirable; in such cases 
it is necessary to anoint only that hand or portion of the hand which 
comes in contact with the tissues under investigation. It is also an 
advantage sometimes to introduce vaseline into the crevices around the 
finger-nails. 

An equally efficient and in many respects a much better safeguard 
against infection is the use of rubber gloves. Those should be selected 
" which are neither too thick nor too thin, and not the old-fashioned 
thick, black, red, or white gloves. They should be provided with 
long sleeves, and should be purchased from a reliable dealer who has 
not had them too long in stock, as they markedly deteriorate by age. 
They fit snugly, and are especially useful when opening the stomach 
and intestines, as it is most frequently the intestinal contents which 
impart the odor that adheres so persistently to the hands. They do 
not prevent, though they to a certain extent hinder, the production of 
post-mortem wounds. After use they should be washed both inside 
and out with water to which a little washing soda has been added 
and scrubbed with a nail-brush until clean, rubbed lightly with a towel 
or absorbent lint until thoroughly dried, and then carefully dusted 
with powdered soapstone or with talcum powder. Either the weight 
of the water or pressure of the air may be used to force the everted 
fingers straight. With care rubber gloves may be sterilized in the 
autoclave. They should never be put away moist or dirty. Small 
openings may be patched in the same manner as a bicycle or auto- 
mobile tire. Should the postmortem be upon a metallic poison case, 
a new pair of gloves should be used, and another pair from the same 
lot reserved unused for possible future examination by the chemist. 
Those of us who have made many hundreds of autopsies with our 
naked hands feel that we lose that delicacy of touch so desirable in 
post-mortem work when gloves are employed. Letulle, 1 in his recent 
work, enteres into a tirade against their use. The coming generation 
will, however, undoubtedly wear them, or employ some such sub- 
stitute as that recommended by Murphy, 2 of Chicago, who has re- 
cently suggested a method of dispensing with gloves in surgical opera- 

1 La pratique des autopsies, 1903. 

2 Jr. Amer. Med. Assoc, Sept. 17, 1904. 



. I'OSTMORTKM KXAM INATIONS 

tions. This consists in the application to the hands of a four to eight 
per cent, solution ni gutta-percha iii benzin or acetone, the former 
giving the better satisfaction in routine practice, as it is more lasting. 
The coating may have to he renewed during the operation, and when 
removed, by washing in benzin, leaves the hands soft and smooth. 
Rubber finger-stalls, especially the variety known as the seamless 
rolled finger-cot, which unrolls as it is placed on the finger, are useful 
if the operator have any hangnails or other abrasions of the fingers. 
They often break, however, during the performance of the autopsy. 
Blood, pus, or other fluid should not be allowed to dry upon the 
instruments used, upon the gloves, or upon the hands, for it not only 
impairs the delicacy of touch so desirable in this work, but may also 
cause unsightly stains upon the skin, which are difficult to remove, 
especially when certain preservatives have been employed in embalm- 
ing the body. 

The hands may usually be freed from odor by applying to them, 
while still wet, either a few drops of turpentine, formic aldehyde 
(from one to two per cent.), aromatic spirit of ammonia, listerine, 
paregoric, or mustard, and then washing them thoroughly with a 
good glycerin soap. Neelsen (quoted by Nauwerck) states that, if 
the odor can be removed in no other way, equal parts of fuming 
hydrochloric acid and glycerin may be used. The employment of 
equal parts of hypobromite solution (used in the quantitative esti- 
mation of urea) and of water, while severe, is also very effective for 
this purpose. 

For disinfection of the hands after the postmortem one may use a 
creolin solution, made by placing about an ounce of creolin in a basin 
of tepid water ; l a mixture of two teaspoonfuls of acetic acid, twice 
this amount of calx chlorinata, and a quart of water; bichlorid solu- 
tion i to iooo; or a concentrated solution of potassium permanganate. 
The brownish discoloration of the hands may be removed by apply- 
ing to them while still moist either oxalic acid or a concentrated 
aqueous solution of the bisulphite of sodium to which has been added 
a small amount of chlorin ; or an antiseptic soap may be employed. 
Of the latter, I prefer the one per cent, bichlorid of mercury soap, or 
a ten per cent, lysol solution made with the tincture of green soap. 
Of course, any of the surgical methods in vogue for disinfection of 

1 Or, more exactly, a two per cent, creolin solution. 



POST-MORTEM WOUNDS aj 

the hands may be employed. At the end a sodium bicarbonate wash 
and the application of a little lemon juice leave the hands in good 
condition. A brisk walk in the open air is also to be advised after 
the completion of the autopsy. 

A post-mortem wound, as usually referred to, means not only a 
break in the continuity of the skin by an accidental incision, puncture, 
or other injury received at an autopsy, but also the inoculation therein 
of pathogenic bacteria from the cadaver, and their subsequent multi- 
plication in the system, with the production of toxic symptoms. 
Wounds presenting similar appearances may, of course, be derived 
from many sources, as from surgical operations or from other post- 
mortem wounds. The intact skin of the hand is a perfect protective 
against the invasion of bacteria. In order that the organisms may 
infect the body, there must be both a point of entrance and a pre- 
disposition or lack of immunity in the individual affected. While 
any of the infectious diseases may be contracted in making a post- 
mortem, those most to be feared are tuberculous warts, syphilis, 1 
gonorrhceal ophthalmia, tetanus, anthrax, glanders, plague, actino- 
mycosis, typhus fever, yellow fever, cholera, and smallpox. I have 
seen septicaemia, general tuberculosis, ulcerative endocarditis, puru- 
lent meningitis, boils, whitlows, etc., follow post-mortem wounds. 
Several years ago one of my patients, who is now a justly celebrated 
veterinarian, suffered from a tuberculous wart which he had evi- 
dently contracted from a cow, thus adding another case to the list of 
those affected with bovine tuberculosis. 

The results of a post-mortem wound depend very much upon the 
general health of the one affected, and experience seems to show that 
severer symptoms and slower convalescence may be expected in those 
who are habituated to the use of alcohol. Inoculations from serous 
surfaces are especially to be guarded against, as from some of the 
varieties of peritonitis due to criminal abortion, and other forms of 
septic peritonitis, meningitis, or pleurisy. Among other virulent kinds 
of post-mortem wounds may be mentioned those derived from cases 
of pyaemia, of septicaemia, of puerperal fever, of malignant oedema 
and diffuse cellulitis, of erysipelas, and of gangrene. Infection by 
the Bacillus pyocyaneus may cause long-continued high temperature 

1 J. de Lisle (Amer. Med., Sept. 19, 1903) writes, " Medical records furnish no 
instance of a specific contamination resulting from a wound received during the 
autopsy of a syphilitic cadaver." 



4J POST-MORTEM EXAMINATIONS 

with little local manifestation, as in my own case when I became 
inoculated with this organism from a case of cancer of the gall- 
bladder with secondary infection by this bacillus. 

It is often asked why post-mortem wounds and injuries received 
in the performance of similar operations are more dangerous than 
th«>sc which arc otherwise inflicted, though containing the same 
organism. Their greater virulence may in part be due to the fact 
that they arc usually punctured wounds, in which the organisms are 
implanted deeply in the tissues, especially in cases of tetanus, which 
is due to an anaerobic bacillus. Again, it is well known that many 
organisms become more virulent by passing through successive 
animals, and, therefore, an organism which has overcome the resistance 
of the tissues and killed them is naturally more destructive than one 
which has not had such favorable opportunities for growth. It has 
been shown experimentally that bone-marrow possesses marked bac- 
tericidal properties. It is a well-established clinical fact that wounds 
produced by sharp spicules of bone are unusually severe. The reason 
given for this is that bacteria which have already overcome the in- 
creased resistance of the bone-marrow have now been introduced into 
the body. 

Post-mortem wounds are generally caused in one of four ways : 
first, by the operator injuring himself with instruments used in the 
making of the autopsy, especially sharp-pointed knives and the saw; 
second, by scratches or punctures from ragged bones or calcified 
tissues, as the ribs or atheromatous patches of the aorta which have 
undergone calcareous infiltration; third, by inoculation of pre-exist- 
ing wounds, abrasions, small eruptions, especially at the roots of the 
hair-follicles, hangnails, blisters, fissures in chapped hands, by infec- 
tion from unsterilized instruments, by subsequent injuries received 
upon unsterilized hands, etc.; and, fourth, by cuts and scratches acci- 
dentally inflicted by the operator on his assistant, as in opening the 
head. Indeed, so frequently does the latter occur that a helper to 
ly the head should be dispensed with unless his hands be thor- 
oughly protected by some covering, such as a towel. Some of the 
usual ways of producing wounds which are especially worthy of men- 
tion are by the operator cutting towards instead of aw^ay from himself 
or his assistant; by leaving a knife in one of the cavities and for- 
getting its presence; by placing his instruments in a dangerous posi- 
tion on the body, the table, or the ice-box; by the use of sharp-pointed 



TREATMENT OF POST-MORTEM WOUNDS ^ 

knives; by punctures from the needle made during- the sewing up 
of the body; and by the too rapid passage of thread through the 
hands, producing a sort of brush-burn. Ragged wounds, such as 
those caused by the saw or by bones, are especially to be dreaded, for, 
being both punctured and lacerated, they are peculiarly prone to 
become infected. 

The micro-organisms present at a postmortem made several days 
after death are apt to be less virulent than those encountered soon after 
dissolution, the saprophytes having now gained the mastery. Other 
things being equal, the more quickly the patient died after infection, the 
more dangerous will be the post-mortem wound ; but the character of 
this lesion and the nature of the organism must always be considered. 
Undoubtedly, persons making many postmortems become immune to 
inoculation by the ordinary Staphylococci and Streptococci. When 
toxins are introduced along with the bacteria, the constitutional symp- 
toms are apt to be more severe, as the toxins overcome a certain 
amount of vital force at the point of infection of the tissues which 
would otherwise aid in combating the micro-organisms. 

As is well known, the bleeding of a wound is a considerable pro- 
tection thereto; hence its immediate closure by the application of 
caustics or of celloidin is worse than useless. If the finger be 
wounded, it should be wrapped with a miniature Esmarch band and 
allowed to bleed freely under running water for at least five min- 
utes, or the part may be washed in distilled water made alkaline by 
the addition of sodium bicarbonate, cleansed with equal parts of 
alcohol and ether, and then washed with an antiseptic solution. Suck- 
ing of the wound after cleansing has been practised. If a caustic 
be used, there is probably nothing better than glacial acetic acid, 
carbolic acid, or pure bromin. The employment of the actual cautery 
is advisable in some cases, but it must be so thoroughly applied that 
no pathogenic organisms are left behind, as otherwise the necrosed 
tissue affords a favorable medium for their growth. An antiseptic 
dressing of moist bichlorid of mercury gauze or dry sterile gauze is 
now applied, which should be renewed every twelve hours. On the 
slightest indication of pus or a deadish-gray appearance of the edges 
of the wound, it should be freely incised, thoroughlv curetted, cleansed 
with a sterile salt solution, dusted with iodoform, and protected with 
a wet bichlorid dressing; or a solution of silver nitrate may be applied 
with benefit. I have seen no good effect from the local use of the 



44 POST-MORTEM EXAMINATIONS 

unguent um Crede (ointment of fifteen per cent, soluble metallic 
silver). The frequent application of hot flaxseed poultices contain- 
ing a teaspoonful of Labarraque's solution is most grateful when the 
wound is discharging. Several inches above the wound a ring of iodin 
should be plentifully painted. Intravenous injections of antitoxic sera, 
collargol, formalin, and silver nitrate have been practised by some with 
alleged benefit in septic affections. Hume injects intravenously five 
hundred cubic centimetres of water containing one-half cubic centi- 
metre of a ten per cent, solution of the nitrate of silver at a tem- 
perature of from no° F. to 115 F. 

Involvement of the lymphatics, as manifested by red lines run- 
ning up the arm, usually on the inner surface, and tenderness in the 
axilla, indicates danger, and shows that the infection is no longer a 
local one. Inflammation of the lymphatics of the axilla may cause 
the glands in this region to become tender and enlarged, so that an 
incision is necessary ; and in cases of axillary cellulitis, even though 
the wound of inoculation be small, early opening should be employed. 
Quinine is useful in these cases, and phosphoric acid and iron may 
be prescribed later. The affected arm should be carried in a sling, 
tonic treatment with changes of air instituted, and a surgeon con- 
sulted, who will treat the case according to the character of the 
wound, the nature of the infection, and the constitution of the patient. 
When healing has begun, massage has made many a serviceable finger 
or hand out of what would otherwise have been a stiff and useless one. 

The anatomical wart is a local tuberculous lesion, often multiple, 
and is usually situated on the back of the hand or at the inner joints 
of the fingers. There is a warty thickening of the papilla of the 
skin, accompanied by a discharge of thin serous pus, but with no true 
ulceration. The sensation produced is similar to that caused by a 
splinter, which, however, subsides for several days after the removal 
of the fluid contents. The lesion sometimes heals spontaneously, but 
may give rise, as in one of my cases, to general tuberculosis. Wet 
dressings, combined with an application of equal parts of glycerin 
and extract of belladonna, may be employed, or the following mixture 
applied : 

\i Salicylic acid, 10 parts ; 
Extract of cannabis indica, 
Cocaine hydrDchlorate, of each 1 part; 
Oil of turpentine, 5 parts; 
Glacial acetic acid, 2 parts; 
Collodion, 100 parts. 



TREATMENT OF POST-MORTEM WOUNDS 4 c 

It would be interesting to try the hypodermic injection of tuberculin, 
or some of the newer forms of treatment of lupus of the face, as that 
of the concentrated rays of light recommended by Finsen. 1 In one 
of my cases treated by the X-rays in 1896 I thought that an ana- 
tomical wart was rendered worse by their use. When tuberculous 
warts have lasted several months, surgical treatment should be insti- 
tuted, care being taken to remove them in their entirety without cut- 
ting into the diseased area. Guinea-pigs injected with such material 
usually linger a long time ; in one of my cases over six months elapsed 
before the animal died from general tuberculosis. 

Suppuration of the matrix of the nails can often be cured only 
by the removal of the nail, though frequent soaking of the finger in 
a hot saturated solution of boric acid or a strong solution of lead sub- 
acetate may be tried. Gwilym G. Davis recommends soaking the nail 
in a strong solution of silver nitrate — twenty grains or more to the 
ounce — and then wrapping the part in a moist bichlorid of mercury 
dressing. Dropping on a saturated solution of iodoform in ether has 
also been tried. Diffuse cellulitis should be treated by early and free 
incision and by the application of compresses. When the hand itself 
is involved in spreading gangrene, amputation should usually be prac- 
tised. If tetanus is feared, the wound should be laid open and the 
area of contagion, if possible, removed, powdered antitoxin applied to 
the part, and the general health of the patient sustained. The sub- 
dural use of the antitoxin and, better still, the direct injection into the 
spinal canal have recently been employed. 

If the knives used in post-mortem work were thoroughly sterilized 
after each necropsy, there would be fewer infected wounds. The 
making of autopsies is undoubtedly dangerous, and therefore those 
who perform them frequently should insure themselves in one or other 
of the accident companies which contain a clause giving a claim for 
benefits in case of wound-infection. As these companies generally show 
a marked disposition to dispute claims, every injury, no matter how 
slight, should be reported to them as soon as possible after its occur- 
rence, so that any subsequent deformity or illness may thus be ac- 
counted for. 

1 Bie, International Clinics, vol. iii.. Eleventh Series, 1902. 



CHAPTER V 

EXAMINATION OF THE EXTERIOR OF THE BODY 

Signs of Death. — The signs of death are of two kinds, — those 
which manifest themselves immediately upon the extinction of life 
and those which appear only after the lapse of a shorter or longer 
period of time, and vary at the time of dissolution according to the 
age, muscular state of the body, disease, presence of certain poisons, 
etc., and the external conditions surrounding the body. The later signs 
are the more positive, but the earlier ones are of more importance from 
a utilitarian point of view. Taken individually, each sign may be 
inconclusive, but when considered collectively they give a scientific 
authority to the generally only too apparent fact that death has taken 
place. Cases of trance and the Indian fakirs afford the best illustra- 
tions of suspended animation. Authentic instances of persons having 
been buried alive during suspended animation are almost unknown, 1 
investigation of the newspaper accounts of such premature interments 
in almost every instance showing their falsity. In Munich the popular 
belief in such occurrences is so great that the bodies of those dying 
in the higher walks of life are kept for several days previous to burial 
in a specially prepared room, a bell being placed in the hands of the 
corpse for the purpose of summoning an attendant in case of resuscita- 
tion. Such notions usually originate from careless handling of the 
coffin, from the expulsion of a foetus by the formation of gases in the 
body of a pregnant woman, from real or apparent growth of hair, 
from conversion of bodies into adipocere, etc. In a judicial hanging 
the murderer is ordered to be hung by the neck until he is dead. The 
responsibility of fixing this time naturally evolves upon the physician. 

The earlier or negative indications of death are first of all insensi- 
bility and inability to move, often preceded by the so-called death-rattle. 
There are loss of sensitiveness to stimuli, loss of reflexes, and the 
cessation of all tissue vitality, though in cases of sudden death sper- 
matozoa will often be found in movement twenty- four hours after 
decease and atropine will dilate and physostigmine will contract the 

1 See Icard, Presse med., No. 66, 1904. 
46 



EXAMINATION OF THE EXTERIOR OF THE BODY 47 

pupils as long as molecular life exists in the ocular tissues. Loss of 
nervous and muscular irritability is determined by application of light 
to the eye, of snuff to the nose, or of cold, heat, force, electricity, or 
other irritants to the skin. Rosenthal considers the existence of elec- 
trical contractility in a dead body to be an indication that death has 
taken place within two to three hours. After the head is severed by 
the guillotine the eyes may open and close and in amputated limbs 
muscular twitchings may often be seen even after their complete re- 
moval from the body. Associated with the change in muscular tonicity 
is the facial expression. During the period of relaxation the visage 
is pale and flaccid, except in very rare cases, where the face even im- 
mediately after death has a red color and there is a drawn, contracted, 
painful expression, the so-called fades hypocratica. 

Much more positive signs are the entire and continuous cessation 
of the respiration and circulation. As a rule, respiration stops a 
moment or so before the heart-throbs and ceases sooner in infants 
than in adults. The absence of breathing may be determined by 
auscultation and by the lack of motion of a down feather or small 
flame held before the lips or by the absence of the deposition of moist- 
ure on a cold mirror. A glass of water or of mercury placed upon 
the epigastrium will show a ripple on its surface if there be the slight- 
est movement of respiration (Winslow's test). The X-rays have also 
been used to detect any activity of the heart and lungs. 

Most of the minor signs of death depend upon the absence of 
circulation. This is determined first by observation. The skin of a 
dead person acquires almost immediately a leaden pallor or lividity 
and loses its transparency. The mucous membranes become pale and 
exsanguinated. The hands if viewed by strong transmitted light show 
no pink tinge where the fingers come in contact (diaphanous test). 
The palms and soles of the feet become more or less yellow in color. 
By palpation and auscultation the absence of pulse and heart-beat can 
be determined. A small artery, as the temporal, may be incised and 
examined; after death it will be found empty and its lining will be 
of a pale yellow color. The mercury in the manometer records zero. 
Scarification or cupping on a dead subject causes no flow of blood, 
while ammonia injected subcutaneously produces no congestion. In 
Icard's test fluorescin is injected subcutaneously; if life be present, 
local discoloration soon appears and the staining material may be 
chemically detected in blood abstracted at a distance from the point of 



jS POST-MORTEM EXAMINATIONS 

injection. A tight ligature around a finger, a limb, or the lobe of an 
ear will give rise to no reddening (Magnus's test). Pressure applied 
to a finger-nail will drive the blood away, leaving a white area, which 
will again be filled with blood if there is any circulation. If a flame 
or beat <>\ any kind, as from melted sealing-wax, is applied to the 
skin, and a vesiele is formed, the blister on the dead skin will contain 
a non-albuminous fluid and the underlying cutis vera will remain dry 
and glazed, while in the living the contents will be rich in albumin 
and the cutis vera will be reddened. Caustics applied to dead skin 
will form no eschar, but may make the skin yellow and transparent. A 
steel needle plunged into a muscle after death has occurred will not 
be oxidized, even though it remain in place for many hours, but would 
tarnish in ten seconds if life were present (Glaister). 

Besides these tests, there are changes in the eyes which are very 
important signs, and are in a great measure due to the loss of circula- 
tion. The fundus oculi is of a pale yellowish white and its vessels 
are empty or the column of blood in them is beaded by the presence 
of bubbles of gas. There is a marked loss of elasticity in the eyelids 
and in the globe. The eye collapses, sinks back in the socket, and ap- 
pears flat and wrinkled ; it loses its lustre and presents a glazed appear- 
ance. In some cases it is soft and flabby and may be covered with 
viscid mucus; more rarely, as in apoplexy or hydrocyanic-acid and 
carbonic-acid poisoning, it remains bright, full, and prominent for a 
considerable time. The conjunctiva quickly becomes cloudy and gray. 
The cornea may become opaque immediately after death or during the 
last hours of life; in other cases it does not change until the lapse of 
several hours. The cornea, iris, and conjunctiva lose their sensitive- 

3. In the last agony or shortly after death the pupils dilate, and 
again in about an hour they contract, as a rule unequally; this con- 
traction lasts for three or four days. The loss of elasticity in the eye is 
very marked ; the pupil can be made oval and will remain oval by 
synchronously compressing the globe (Ripault's test). This may, 
however, occur before death. 

Another sign is complete loss of vital warmth. This occurs 
more rapidly at first than on nearing the temperature of the sur- 
rounding atmosphere. Clothing, fat, etc., cause the lowering to take 
place more slowly. Wilks and Taylor show that at an average tem- 
perature a nude dead body cools at the rate of about one degree 
Fahrenheit per hour. A body placed in water will cool more rapidly 



EXAMINATION OF THE EXTERIOR OF THE BODY 4Q 

than in air of a similar temperature, and refrigerants naturally 
reduce the temperature quickly. Nysten finds 1 that the bodies of 
those killed by lightning or by suffocation retain their heat longer 
than when death is due to other causes. Post-mortem cooling requires 
at least twenty-three hours for its completion. Brouardel says that 
the rectal temperature ordinarily is the same as that of the room in 
about forty hours. In the bodies of those who have died from some 
of the zymotic diseases, as cholera, tetanus, variola, etc., from injuries 
to the nervous system, or from certain abdominal disorders, the tem- 
perature may rise soon after death, and an elevation is also noted dur- 
ing the period of muscular rigidity. Where decease is due to some 
chronic affection chilling is slow, while after fatal hemorrhage it is 
very rapid. 

The most positive sign of death is putrefaction, which appears after 
a longer or shorter time, and manifests itself first by a prominence 
of the superficial veins and by a greenish color in the iliac fossae and the 
centre of the abdomen, later on the genitalia and thighs. Finally the 
whole body is involved. It becomes purplish red in color, due to the 
posthumous circulation, which is a displacement of the blood from the 
heart and large vessels by the pressure of the gases of putrefaction 
formed in the abdomen. Mummification and adipocere show that death 
took place some time ago. 

POST-MORTEM OR CADAVERIC LlVIDITY ; HYPOSTASIS OR HYPO- 
STATIC Congestion. — Unless drained of its blood by previous hemor- 
rhage, a corpse usually shows a bluish-red to purplish-red discoloration 
on its most dependent parts, due to the cessation of the circulation and 
to the gravitation of the blood to those organs. The discoloration does 
not, however, appear upon those portions of the body upon which it di- 
rectly rests. It will at once be seen that this fact may afford a basis upon 
which to form an opinion as to the position in which a body has lain 
after death. Post-mortem lividity rarely comes on before five hours ; 
it reaches its maximum in the second day. It shows itself not 
only on the exterior of the body, but also on the dependent parts of 
such internal organs as the posterior wall of the stomach and the 
temporal lobes of the brain. Cadaveric lividity may resemble a bruise 
made during life, with all its various forms and shades of color. The 
distinguishing features are: (i) The discoloration in post-mortem 



1 Arch. gen. de med., June, 1862. 
4 



5Q POST-MORTEM EXAMINATIONS 

lividity disappears on pressure, while that due to a bruise does not. 
(2) A patch of post-mortem lividity will bleed freely when incised, 
because the vessels in the dependent parts are engorged with blood, 
while from a bruise there is little or no oozing, as the original hemor- 
rhage is circumscribed and the discoloration is due to extravasated 
staining of the tissues and not to the actual presence of blood. An 
incision into the affected area should therefore be made in all suspected 
cases, especially in those of a medicolegal character. If the part be 
washed with running water, blood will appear again and again in 
hypostatic congestion. The two conditions are more closely simulated 
in those rare cases of hypostasis where we find a post-mortem cedema- 
tous infiltration and enlargement of the adjacent tissue. Should such 
exist or should the two conditions be combined, it is well to free the 
suspected area from the hypostatic congestion by turning the body on 
the opposite side for several hours before describing the bruise. As 
a rule, the more fluid the blood, as in cases of death from suffocation, 
the acute infectious fevers, poisoning by hydrocyanic acid, etc., the 
more marked will be the post-mortem lividity. In the latter case, as 
well as in poisoning by illuminating gas, the lividity may be of a char- 
acteristic rose-red color. 

Bodies which have been kept for a long time (or a shorter time 
under unfavorable conditions) after death, especially during cold 
weather, present another form of cadaveric lividity which is charac- 
terized by a uniform reddish tint. This is caused by the diffusion of 
haemoglobin from the blood-vessels into the surrounding tissues (im- 
bibition). This form of lividity is most conspicuous along the course 
of the superficial veins and is not affected by pressure. 

It is important to distinguish between post-mortem lividity and the 
greenish discoloration of commencing decomposition, usually first seen 
over the abdomen. According to some authorities, the greenish color 
is due to the precipitation of the iron of the haemoglobin by the hydro- 
gen sulphid arising from the decomposition of the tissues under the 
influence of bacteria, while others teach that it is due to chromogenic 
organisms themselves or a pigment elaborated by them of iron, potas- 
sium, and cyanogen. In one of my cases such discoloration was 
mistaken for the effects of personal violence, and serious allegations 
based upon this error were made against the husband of the deceased. 

Post-Mortem Rigidity or Death-Stiffening. — The involun- 
tary muscles first show contraction, and it is doubtless this action 



EXAMINATION OF THE EXTERIOR OF THE BODY 5I 

which sometimes causes the expulsion of a foetus after death. Post- 
mortem rigidity commences externally in the muscles of the lower jaw 
and spreads downward, disappearing in the same order, though 
Lacher, from an examination of six hundred bodies, found the con- 
dition to occur last in the arms. In ordinary cases it begins about 
two hours after death, is complete in from seven to eighteen hours, 
and ends as the stage of putrefaction comes on, in three or four 
days. Brown-Sequard quotes a case of typhoid fever where rigidity 
came on in less than four minutes, disappeared in a quarter of an 
hour, and putrefaction commenced in one hour after death. The 
stronger the individual and the shorter the duration of the fatal dis- 
ease, the more prompt and marked will usually be the rigidity. The 
bodies of soldiers killed by being shot in battle after forced marches 
sometimes retain the position they occupied when they were hit, in 
certain cases even remaining erect when killed standing. The case of 
Captain Nolan at Balaklava is often cited in this connection, where it 
is alleged that he held a sword and with distended arm rode on 
horseback in the charge after death had ensued. The position of the 
hands produced by this muscular rigidity is also an important sign. 
The thumbs are usually flexed across the palms and the fingers flexed 
over the thumbs. Instantaneous rigor of the hand of a suicide may 
occur, a weapon being grasped tightly in the hand. This condition 
cannot be reproduced artificially, and shows high mental tension, 
nerve excitement, suicide, and not murder. Rigidity is marked, espe- 
cially in the abdominal muscles, after death from cholera. The body 
of one who has died from tetanus, strychnine, or other spinal poison, 
as veratrum viride, may lie supported only by the head and heels, or 
when placed upright may stand erect with little or no support. In one 
of my cases of strychnine poisoning rigor mortis was present on dis- 
interment twenty-four days after death. Suffocation causes long-con- 
tinued post-mortem rigidity. Chronic alcoholism delays and prolongs 
it. The more muscular the individual, the slower is it in coming 
on and the longer in going off. Rigidity disappears more quickly in 
cachectic subjects, and is sometimes almost entirely absent after heat- 
stroke. The process does not depend upon the nervous system, but 
upon changes taking place in the sheaths of the individual muscular 
fibres. Section of one ischiatic nerve will delay, but not prevent, 
rigidity. 1 Laceration of muscles retards or may even preclude this 

1 Bierfreund, Arch. f. d. ges. Phys., 1888. 



e 2 POST-MORTEM EXAMINATIONS 

condition. The reaction of the muscles is at first acid, due to sarco- 
lactic and other acids. As the rigor mortis passes off the parts become 
alkaline, a condition natural to a decomposing body. It should be 
remembered that in the preparation of the body by the undertaker the 
rigidity may have been overcome by force; this is especially true of 
the elbows. Be careful, on the other hand, not to be deceived by a 
previously existing ankylosis. Rigidity may be overcome by the use 
o\ hot applications, but when it has once disappeared it seldom returns 
and is never again so pronounced as at first. Rapid cooling delays 
rigidity, which, however, passes off the more quickly when the body 
i^ once more made warm. This condition must be differentiated from 
freezing, where on reduction there is a crackling sound. Cadaveric 
rigidity does not occur in the immature foetus. 

Decomposition. — The bodies of infants decompose more quickly 
than those of adults. The process begins earlier in plethoric and 
fat adult bodies than in thin aged persons. It is more rapid after 
muscular activity and in those dead of acute diseases, fevers, heat- 
stroke, sepsis, suffocation by gases, etc., while it is longer delayed in 
cases where the system is exhausted and muscular irritability retarded, 
and in the bodies of those fatally poisoned by hydrocyanic acid, 
carbonic acid, sulphuric acid, etc. Arsenic may or may not prevent 
decomposition. At the same temperature a body which has been 
for one week in the air, one which has been two weeks in water, and 
one which has been eight weeks buried will show similar degrees 
of decomposition. (Brown-Sequard.) 

Hofmann recommends in cases where decomposition is much ad- 
vanced the removal of the brain in the ordinary manner, the making of 
some openings in the skin, the washing of the entire body in running 
water for twelve hours, and the further bathing of the corpse in a con- 
centrated alcoholic sublimate solution or chlorid of zinc for an equal 
period. The green coloration due to decomposition disappears to a 
marked degree under this treatment. 

The length of time which has elapsed since death has to be deter- 
mined by the circumstances peculiar to each case. So many considera- 
tions may apply that in many instances it is dangerous to be too 
dogmatic. 

External Examination of the Body. — It is of great impor- 
tance that we should not confine ourselves solely to the examination 
of the corpse, but should, in addition, carefully scrutinize the clinical 



EXAMINATION OF THE EXTERIOR OF THE BODY r^ 

history, weigh the evidence derived from a personal survey of the 
surroundings, consider the circumstances under which death occurred, 
and question the persons who came in contact with the subject just 
before and after death. Data derived from such sources are of especial 
value in medicolegal cases or when a postmortem is to be performed 
upon an unidentified body ; but the knowledge acquired by inspecting 
the surroundings and the exterior of the cadaver must in no way bias 
the operator before the internal examination is made, as the unex- 
pected may happen here as well as elsewhere. The naked body is 
then to be minutely inspected, first as a whole for symmetry and then 
both anteriorly and posteriorly as to its component parts, proceeding 
in a definite and orderly manner. It would indeed be to our advan- 
tage in acquiring pathologic knowledge if the living body in the nude 
state were more frequently made the subject of careful study, for the 
information thus obtained is often of the greatest value to the clinician 
and surgeon. 

Identification of the Body. — Before a postmortem is begun, 
the remains should, if practicable, be positively identified to the 
obducent by one or more persons who knew the individual during life. 
If this be impossible, the one who found the cadaver or those who 
saw it in its original situation after death and those that removed it 
from one place to another may act as identifiers. Persons who have 
gone under several names should be recorded under their legally 
correct names, any aliases which had been used being also recorded. 
Certain details, such as articles of clothing, jewelry, and even pawn 
tickets, sex, age, height, weight, birth-marks, angioma, moles, tattoo 
markings, condition of the teeth, anomalies of the ear and eye, deformi- 
ties, wounds, scars, or even the evidence of certain diseases, are of 
great importance and may often be the sole means of identifying the 
body. Should personal identification be impossible, a cast of the face, 
a photograph, and an accurate description of the body, with a full and 
clear statement of any peculiarities, should be made. In some cases 
a wax cast of the interior of the mouth, made afterwards in plaster, 
may be helpful. As the person whose body is being examined may 
have been a criminal and thus during life have had the Bertillon 
system applied for purposes of future identification, these measure- 
ments and finger-impressions should be secured in important cases. 
Skiagraphs of old osseous lesions, as well as a record of the teeth of 
the decedent and of their peculiarities, might also lead to identifica- 



- 4 POST-MORTEM EXAMINATIONS 

tion. Qothing alone is not sufficient for purposes of identification, as 
bodies have been substituted and clothed in the wearing apparel of the 
alleged deceased, such substitutions being made in order to defraud 
life-insurance companies or change succession to titles and estates. 

Care of Clothing and a Study of the Surroundings. — The 
clothes may greatly assist the legal authorities in the prosecution of a 
case, as in showing' the entrance but not the exit of a bullet. In such 
cases, where the clothing has not been already removed by responsible 
persons before the arrival of the physician, as is done in certain places 
(though this is scarcely justifiable), the examiner should observe the 
condition of the articles and their position, whether torn or soiled, 
displaced or reversed. If any irregularity is observed, he must deter- 
mine, if possible, what significance may be attached thereto. For 
example, singeing about a recent small bullet-hole, with the powder 
markings pointing upward, would indicate that the powder used was 
black and not smokeless, that the weapon was discharged at close 
range, and that the trigger was held in the opposite direction, — i.e., 
down. 1 (Plate VI.) Again, seminal stains with marked disarrange- 
ment or tearing of the clothing of a female would strongly suggest — 
at least an attempt to commit — rape. The clothing in all such cases 
should, therefore, be preserved. Before securely wrapping and label- 
ling, such perishable articles as one has decided to preserve should be 
disinfected and gum camphor or tar camphor added, in order to pre- 
vent their destruction by moths, as it is disappointing at or just before 
the trial to find the material so badly moth-eaten as to be useless for 
demonstrative purposes. Spots to be remembered, such as those made 
by blood or seminal stains, should be designated with thread or ink 
and a careful note made as to their exact location. In handing over 
to the proper legal officers articles for future use, it is well to place 
upon them in the presence of a reliable witness some mark of identifi- 
cation and to get a receipt for every article so delivered. The desire 
of the police to be on friendly terms with the reporters often renders 
the proper study of the surroundings impossible or misleading. In 
one of my case- — a brutal murder by violence — the scene had been 
visited by scores of persons and the body removed to an undertaker's 
before the writer was summoned to perform the autopsy. The im- 
portance of ascertaining the nature of the substance upon which the 

' Brixton, International Clinics, October, 1902. 



EXAMINATION OF THE EXTERIOR OF THE BODY y 

body rested when found was shown in another postmortem by my 
rinding in the rectum of a four-year-old boy " needles" from a Christ- 
mas-tree and a similar " needle" upon the hat of the murderer and 
sodomist many blocks from the place where the crime was committed. 

That the place where an unidentified body is found should be care- 
fully stated is shown by one of my cases. A colored woman confessed 
the placing of the corpse of a new-born male bastard wrapped in a 

shawl in an ash-barrel on the corner of A Street, Philadelphia, 

Pennsylvania, in which State the concealment of the death of an 
illegitimate child is a penal offence. The body identified at the post- 
mortem was that of a new-born colored babe wrapped in a shawl, but 

found in an ash-barrel situated at the corner of B Street, some 

two blocks away. On the plea of the lawyer for the defence that there 

was no corpus delicti, as the body found at B Street was not 

shown definitely to be the body left at A Street, the judge decided 

that the trial should not proceed and ordered the jury to acquit. This 
was at once done, and, though new evidence might later be secured, 
it could not be used, as the woman could not have her life put in 
jeopardy a second time, though, as in the Mollineux trial, a man 
might once be condemned but on a new trial be acquitted. 

Sex. — The sex is easily determined, except in hermaphrodites, 
where it is sometimes necessary to complete the autopsy and even 
then wait for microscopic sections before deciding as to whether or not 
the question can be definitely settled. An interesting legal question is 
whether an hermaphrodite should be allowed to choose to which sex 
he or she should belong or whether this should be settled by law. 

Race. — As the world becomes more cosmopolitan the racial ques- 
tion must receive more and more attention. It is of especial impor- 
tance to designate mixed races ; thus, in a colored person it is well to 
estimate as closely as practicable the amount of negro blood in the 
body under examination, as mulatto, quadroon, or octoroon. 

Age. — The apparent age should then be carefully considered. By 
apparent age is meant the age of the body as it appears to the judgment 
of the observer at the time of making the postmortem. A person may 
look older or younger than his or her real age, disease, mental depres- 
sion, or dissipation often making the body seem many years older 
than it really is. Per contra, the signs of suffering may pass away, 
the features becoming relaxed and presenting a better appearance 
than they had done for many months before death. If the years cannot 



- f) POST-MORTEM EXAMINATIONS 

be estimated with any certainty, one may be able at least to designate 
the time of life as represented by the seven ages of Shakespeare. 

Height. — The height is determined by measuring in a straight 
line from the vertex of the head to the centre of the external arch of 
the instep, the feet being flexed at a right angle to its plane of sup- 
port. If a scale is not marked on the table and no other means of 
measuring is at hand, a piece of inelastic string or tape may be 
employed for this purpose and measured later. The writer suggests 
the use of a measuring apparatus modelled on the style of a shoe- 
measure. A simple form can readily be made by taking two one-foot 
rulers, or other sticks of about the same size, and attaching, one inch 
from one end, a seventy-eight inch tape-measure, which is made to 
run through a transverse slit one inch from the top of the other ruler. 
If a tape-measure of this length is not at hand, forty- two inches of 
inelastic tape may be sewed together and this attached to a measure 
of ordinary length. The first ruler is held close to the foot which is 
placed in a vertical position, and the other stick is held parallel to the 
first stick by an assistant standing at the head of the corpse, and the 
tape is drawn until it is taut. When not in use the tape-measure is 
wound around the sticks. Next measure the circumference of the 
head and shoulders. Should there be shortening of a limb, or atrophy, 
as in fracture and in infantile paralysis, full measurements of both 
limbs are to be made. 

Certain abnormalities of stature are occasionally seen, such as : 
( i ) Dwarfism, a condition which may be congenital or acquired. If 
acquired it may be either cretinoid or rhachitic, and is often associated 
with sterility, impotence, bone deformities, or atrophy of the thyroid. 
(2) Giantism appears in two types, infantile and acromegalic, which 
arc intimately related. From the literature on this subject, it would 
seem that acromegaly frequently follows giant growth or even the 
period of excessive growth. This condition is often accompanied by 
an abnormal development of the genitalia and changes in the vascular 
glands, especially the pituitary and the thyroid. 

If only part of a body is present, as in the case of Wakefield Gaines, 
where the trunk alone was found, the length may be approximated 
from various data. If the head and upper extremities remain, twice 
the length of the arm from the midsternal line to the tip of the middle 
finger, measured along the flexor surface with the arm in abduction, 
or the distance between the tip of the middle fingers along the flexor 



EXAMINATION OF THE EXTERIOR OF THE BODY 



57 



surface, with the arms extended at right angles to the main axis, will 
about equal the height of the individual. If but one extremity is 
present, twice the length measured from the glenoid cavity plus one- 
half the distance between the glenoids measured between perpendicular 
lines, or nineteen times the length of the middle finger equals the 
approximate height. Other means of computing the height are : ( I ) 
The distance from the tip of the olecranon to the tip of the middle 
finger is five-nineteenths of the height. (2) The upper border of the 
symphysis pubis in an adult is the midpoint of the adult's height, but 
this is not trustworthy in women or persons with deformities. (3) 
From the head of the femur to the plantar surface of the heel is one- 
half the height, while the length of the femur is one-quarter the 
height. (4) Orfila has shown, however, that from one of the long 
bones alone the exact determination of the length of the body is im- 
possible. Manouvrier in cases of extremely short or long bones mul- 
tiplies by coefficients to secure the height, as follows : x 



MEN. 



Femur. 



Tibia. 



Fibula. 



Humerus. 



Radius. 



Ulna 



Less than 
392 mm. 

x 3.92 

More than 

519 mm. 

X3-53 



less than 
319 

x 4.80 

more than 

420 

X4.32 



less than 
3i8 



less than 
295 



Coefficient. 



x 4.82 
more than 
413 



X525 

more than 
368 



Coefficient. 
x 4.37 x 4.93 



less than 
213 

x 7. 11 

more than 

273 

x 6.70 



less than 
227 

x6.66 

more than 

293 

x 6.26 







WOMEN. 






Less than 


less than 


less than less than 


less than 


less than 


363 mm. 


284 


283 263 
Coefficient. 


193 


203 


X3.87 


x 4.85 


x 4.88 


x 5.41 


x 7.44 


X 7. (XI 


More than 


more than 


more than 


more than 


more than 


more than 


478 mm. 


388 


376 


344 


250 


264 






Coefficient. 






x 3 .68 


x 4.42 


x 4.52 x 4.98 


x 7.00 


x 6.49 



1 Rollet has prepared similar tables, which will be found in Vibert' s work, 6th el., pp. 561, 562. 



tjg POST-MORTEM EXAMINATIONS 

The length of the skeleton from the vertex to the calcaneum plus 
from four to six centimetres about equals the height of the individual, 
these figures being added to compensate for the loss of the interartic- 
ular cartilages, the intervertebral disks, and the coverings of the head 
and heel. 

In many cases where homicide has been committed and the mur- 
derer has attempted to destroy the evidence of his guilt, or in de- 
structive accidents, the corpus delicti has been proved by the finding 
of a part or member of the body or a portion of the clothing, as a 
piece oi charred bone, a tooth, as in the Parker case, a ring, or a 
button. On the other hand, instances are on record where deluded 
individuals made confessions of murder which were proved to have 
been unfounded by the subsequent appearance in life of the persons 
said to have been killed. So important is this point that time and time 
again juries have failed to convict where the moral evidence was well- 
nigh conclusive. It is only upon irrefutable evidence that the funda- 
mental principle concerning the corpus delicti is disregarded. 

Where only a part of the body is available for examination, con- 
siderable difficult}- is apt to arise as to the best method of procedure. 
The examiner will then need to possess a wide knowledge of compara- 
tive and pathologic anatomy and to exercise great ingenuity in order 
satisfactorily to demonstrate the identity of the parts submitted. 
Should the only proof of the corpus delicti be a skeleton or a portion 
of one, the expert may be asked to determine the age, race, and sex 
of the person, and the probable date at which death took place, — 
whether the bones are old or recent. With limitations, the age would 
be known by the condition of the epiphyses, whether united or not; by 
the cranial sutures, whether closed or not; and by the state of den- 
tition. Race would be indicated by the different racial characteristics 
and peculiarities: thus, the negro by his splay-foot, projecting heel, 
and prognathous jaw; the Caucasian by his higher forehead, wider 
1 angle, and larger cranial capacity. Evidence of this character 
A by any means conclusive. The determining of sex, after the 
age of puberty, presents less difficulty. In man the size of the cranium 
is greater and all the bony points are heavier and more prominent, the 
angle of the neck of the femur with the shaft is greater, and the lower 
jaw is heavier; in woman the bones are lighter and more compressed, 
the patella is smaller, and the articular surface of the femur and 
tibia is narrower. The characteristic differences are, however, found 



EXAMINATION OF THE EXTERIOR OF THE BODY 59 

in the broad female pelvis, the diameters of which are all greater with 
the exception of the vertical ; the sacrum and coccyx are more curved 
and there is greater spread of the arches of the pubes. 

The probable age of the bones would be indicated by their condi- 
tion and appearance. The presence of the marrow and the periosteum 
is the most conclusive evidence of a recent state. The soft parts are 
usually destroyed within two years. Under ordinary conditions the 
body skeletonizes in about ten years, although this period is subject 
to wide variations, depending upon the cause of death, the chemical 
properties of the soil in which the body was found, and whether or 
not preservatives were used. 

Weight and Nutrition. — Next weigh the body, if this has not 
already been done, or at least estimate its weight. Particularly observe 
the state of somatic nutrition. If emaciation be present, note whether 
it is due to a deficiency of fat (panniculus adiposus), to muscular 
atrophy, or to a combination of both. This can readily be determined 
by picking up a fold of skin over a muscle and rolling it between the 
thumb and fingers. One may study upon his own person the differ- 
ences existing in various parts of the body, noting especially the 
varying thickness of the integument in the front, the back, and the 
sides of the neck. The greatest emaciation occurs in phthisis, atrophic 
cirrhosis, muscular atrophy, and cancer of the upper digestive tract. 
The fat may be the corpulency of a high liver, of a gouty person, or of 
one suffering from cardiac affections. Women have a tendency to 
become obese as they reach the change of life. 

An excessive deposit of fat may be due to adiposis dolorosa, in 
which condition there is a great increase of adipose tissue, not uni- 
formly distributed, but occurring in lumps, the forearms, hands, legs, 
and feet often being without any or with but slight deposits of fat. In 
some cases there is also a thickening of the synovial membranes, with 
a tendency towards the formation of joint fungi and mice bodies, — 
probably a fatty infiltration. In one case reported by Dercum, in a 
man four feet eight inches in height, the patient weighed two hundred 
and six pounds. 

Skin. — Some of the bodies coming to autopsy are so filthy thai 
no true estimate of the condition of the skin can be made until they 
have been cleansed. In vagabondism and alcoholism a distinct cuta- 
neous discoloration often occurs due to the habits of the subject. Lice 
upon the body or head may be quickly and effectually disposed of by 



60 POST-MORTEM EXAMINATIONS 

saturating a towel with chloroform or kerosene and placing it upon 
the part affected for a few moments preparatory to its opening. For- 
malin may be used for this purpose if it can be applied several hours 
previous to the postmortem, so as to allow time for the evaporation of 
its fumes, which are so irritating as to forbid its application when the 
autopsy is to be made immediately afterwards. 

The color of the skin is of great importance. It varies much in 
health and still more in disease and after the appearance of hypostatic 
congestion. Native Africans vary from yellowish brown to jet black. 
The children of negroes are usually creamy yellow when born, while 
it has been stated that the offspring of a mulatto mother and a full- 
blooded negro father is very dark at birth. The integument of a 
cadaver rarely possesses the rosy hue of health, but is rather of a 
grayish white, which shade is most conspicuous in cases of fatal 
poisoning by chlorate of potassium. The skin on those parts which 
have been exposed to the sun is generally more or less tanned, while in 
jaundice the color varies from the faintest tinge of yellow to a dark 
yellowish brown. Yellow color is also noted in chlorosis (yellowish 
green) and in pernicious anaemia (lemon-yellow). In the latter 
brown spots are also frequently found, usually situated on the abdomen, 
groin, buttocks, and thighs. Pallor is due to a primary anaemia or loss 
of blood, and is often so marked as to suggest the possibility of internal 
hemorrhage, as from the rupture of an aneurism or of the sac in extra- 
uterine pregnancy. The cachexias of cancer, argyria, etc., are at times 
peculiarly conspicuous in the dead body. The patches of bronzed skin, 
alternating with unaffected areas, seen in Addison's disease, may be 
scattered over the entire body, but are especially well marked on the 
abdomen; they are also sometimes found upon the mucous membrane 
of the mouth. This bronzing may occur when the suprarenal bodies 
are still apparently normal. Brown lines and a brown areola around 
the navel are observed during pregnancy; patches on the face may 
also appear. A white skin is found in albinism, vitiligo (where it 
occurs in patches), and in leprosy. Moles, tattoo marks, and certain 
cutaneous diseases, as leucoderma, cause characteristic discolorations 
of the integument. Redness of the skin is important. It may be 
simply a discoloration from some red clothing, or an erythematous 
inflammation, which, as a rule, however, disappears post mortem. In 
cases of asystolic cardiac disease a bluish-red cyanosis is often seen, 
but general reddening of the body is more likely to be a post-mortem 



EXAMINATION OF THE EXTERIOR OF THE BODY 6 X 

lividity, though it may be due to congenital or other forms of heart 
disease. 

The breasts should be carefully examined in all cases, and the shape 
and size of the gland noted. The presence of any fluid in the breast 
should be detected by making pressure upon the gland and its char- 
acter described after being placed under the microscope, especially in 
cases of abortion. Certain inflammatory conditions are found in the 
breast, the infection usually entering through a wound, abrasion, or 
fissure of the nipple. The infection may remain localized to the nipple, 
causing a simple ulcer or abscess, or produce a general affection. The 
abscess may be due to infection by the organisms of typhoid fever, 
tuberculosis, etc., the latter being miliary or diffuse. Several cases 
have been reported where the nipple became infected accidentally from 
vaccination. Atrophy of the gland is observed in the old, and hyper- 
trophy is sometimes seen in the young. Supernumerary breasts and 
nipples occur; a well- formed breast with a nipple has been reported 
in the axilla and one in the groin. Tumors are very common in the 
female breast, but rare in the male. They are at times discovered by 
palpation, at other times are visible to the naked eye, and may, as in 
cancer, become great ulcerous patches. The most common tumor is 
cancer, which is most often found in the upper outer quadrant of the 
gland. Paget's disease is an inflammatory dermatitis of the areola 
and nipple, and is often a precancerous lesion. The glands of the neck, 
axilla, and supraclavicular region should be palpated and will often 
be found to be enlarged. Adenocarcinoma, adenocystoma, also known 
as chronic cystic mastitis, adenosarcoma, adenofibroma, adenocystic 
sarcoma, chondroma, myoma, myxoma, round or spindle-celled sar- 
coma, adenoma, lipoma, and fibroma have been found in these glands. 

In the general survey of the body, relaxed abdominal walls, with 
the striae of the multiparas or of the patient who has had ascites, are to 
be described, also the enlargement of the superficial veins so often 
found in chronic heart, lung, and liver disease (especially in atrophic 
cirrhosis), tumors, aneurisms, thromboses of portal vein, etc. Gas- 
troptosis and enteroptosis are often discernible on inspection. CEdema, 
general or local, is investigated especially as to its extent and the char- 
acter of the pitting on pressure. 

Xow examine the skin for any abnormal marks, such as eruptions, 
scars, wounds, bruises, blood, dirt, discolorations, etc. The amount 
of cutaneous injury does not always afford a true index of the lesions 



6 2 POST-MORTEM EXAMINATIONS 

found internally. Thus, it is possible for a wagon or even a street-car 
to pass over a child without leaving any external trace other than a 
brush-burn, though upon opening the body the pelvis may be found 
crushed and the abdomen full of blood. As a rule, all eruptions and 
inflammations of the integument are pale and have a tendency to dis- 
appear at the postmortem. This is especially true of those on the 
mucous membranes and after the administration of certain drugs, as 
the purpuric rash from the use of quinine. The erythema produced 
by potassium iodid and mercury entirely disappears, though mercury 
may cause papules, vesicles, pustules, or even an exfoliative dermatitis, 
lesions which remain and can be studied. 

Even an extreme eruption of measles may disappear post mortem, 
and in these cases, if a study of the lesion be desired, it is a wise pre- 
caution before death to mark the place to be remembered with a der- 
mographic or anilin pencil or by the use of silver nitrate. In other 
diseases, as chicken-pox, smallpox, etc., the eruption is permanent. 
Chicken-pox, which may be coincident with smallpox, starts with 
vesicles that come out in crops. The eruption is very superficial, rarely 
umbilicated, and has no areola; it may become pustular, and often 
leaves scars. The lesions are most profuse on the trunk, especially the 
back, and as they dry up leave a black crust. Smallpox, on the con- 
trary, begins as maculo-papules, which pass into vesicles, and lastly 
form pustules, all three conditions being often found at the same time 
in different parts of the body. The papules are deeply seated, indu- 
rated, and feel like shot when rolled between the fingers. The vesicles 
are multilocular and difficult to rupture. Smallpox may be associated 
with a pre-eruptive general purpuric rash. Malaria may be accom- 
panied by urticaria, angioneurotic oedema, erythema multiforme, bullae, 
herpes zoster, eczematoid eruption, and gangrene. 

The number and variety of skin eruptions are legion, but eczema, 
acne, syphilis, alopecia, and psoriasis form 75 per cent, of all cases 
met with. In skin diseases certain definite lesions are found. Macules 
occur in syphilis, erythema multiforme, pityriasis rosea, pediculosis, 
measles, purpura, scurvy, rheumatism, peliosis rheumatica, extreme 
anaemia, typhus fever, and poisoning from snakes, mercury, antipyrin, 
etc. Brown macules include freckles, chloasma, moles, and naevus 
pigmentosa. White and pale yellow macules are seen in vitiligo, lep- 
rosy, morphcea, and facial hemiatrophy. Vesicles are found in herpes, 
especially around the eyes and the lips, in dermatitis venenata (ivy or 



EXAMINATION OF THE EXTERIOR OF THE BODY 63 

oak poisoning), impetigo, eczema, miliaria, and scabies. Blebs are 
seen mostly in impetigo, where they are flat and umbilicated, pemphi- 
gus, having no areola, dermatitis herpetiformis, and as clusters in 
syphilis. Pustules occur in eczema, acne, dermatitis herpetiformis, 
impetigo, varicella, ecthyma, smallpox, syphilis, scabies, and furuncu- 
losis. Papules occur in lichen, scrofulosis, prurigo, erythema multi- 
forme, after the use of bromids, iodids, copaiba, cubebs, and tar, in 
eczema, miliaria, acne, scabies, syphilis, smallpox, measles, lichen 
ruber and planus. Ulcers are associated with syphilis, epithelioma, 
lupus, trauma, locomotor ataxia, bed-sores, etc. Large tubercles on 
the skin are associated with erythema nodosum, erythema multiforme, 
lupus vulgaris, syphilis, tinea sycosis, and leprosy. Crusting is found 
with eczema, seborrhoea, psoriasis, ichthyosis, syphilis, pityriasis, ring- 
worm, and after scarlet fever. 

Besides these common forms there are other interesting lesions 
which should be looked for, as chimney-sweeper's dermatitis, ulcer- 
ating lesions of syphilis, actinomycosis and anthrax, scurvy and pur- 
pura, circumscribed keratosis, as in cutaneous horns, arsenical poison- 
ing, keratoma, especially the senile seborrhoea of the French authors, 
which occurs in pinhead to dime-sized spots, more or less elevated, 
friable and slightly greasy or dry and hard, with yellow, brown, or 
black crusts which are firmly adherent to the skin and found especially 
on the exposed parts of the body. 1 These lesions, as well as naevi, may 
become epitheliomatous later on. In blastomycosis of the skin the 
lesions are mostly found on the hands, arms, face, and lower extremi- 
ties. Tuberculosis of the skin is rare in this country. It appears in 
several forms, lupus vulgaris being the most common. The anatomical 
wart has been considered in Chapter IV. 

Dermatomyositis sometimes occurs and may be described with the 
skin lesions. It consists of a swelling of the muscles, associated with 
an erythematous and pustular eruption and emaciation. The oedema- 
tous swelling may be followed by desquamation. 

Certain occupations induce special affections, as the inflammations 
peculiar to those working in tar and paraffin, the necrosis of the jaw 
in match-makers, etc. Atrophy of the skin may follow injury to or 
inflammation of nerve-filaments. It at times accompanies pernicious 
anaemia. Induration of skin is seen in scleroderma, myxedema, con- 

1 Hartzell, Jr. of Cutaneous Dis., Sept., 1903. 



64 POST-MORTEM EXAMINATIONS 

genital ichthyosis, and keloid. It accompanies oedema of subcutaneous 
tissues and scurvy, especially in the legs. Trophic affections of the 
skin, especially of the extremities, may be found in puerperal fever, 
gangrenous lymphangitis, diabetes, uraemia, ergotism, locomotor 
ataxia, etc., and is usually present in cases of angioneurotic oedema. 

The yellowish deposits of xanthoma are among the striking and 
peculiar affections of the skin. They are found especially on the 
eyes and in the palmar creases. As one variety may occur associated 
with diabetes, this disease should be always borne in mind. 

Skin eruptions are frequently found with Bright's disease, (i) 
Those of the early stage are pruritus, urticaria, and eczema. (2) 
Those of the final stage are universal erythema and bullous or des- 
quamative eruptions. (3) Purpura or hemorrhagic eruptions may 
occur at any time during the disease, and affections due to marked 
oedema are also present in certain cases. 

The tumors found in the skin are the wen or steatoma, lipoma, 
verruca or wart, nsevus pigmentosus and nsevus vasculosus, morphcea 
or keloid, molluscum fibrosum (which may cover the entire body), 
xanthoma, epithelioma (seen usually on the face), angiomata, which 
may undergo malignant change, adenoma, cancer, and sarcoma. 

An entire chapter might easily be written on the significance and 
value of scars produced in various ways. Those made by the surgeon 
are often from their location self-explanatory, as the cicatrix after 
tracheotomy, trephining of the skull, or the mastoid operation. 1 It 
would, however, certainly facilitate matters, in this age of numerous 
hospitals and frequent operations, if the absence of organs removed 
by operation were indicated by some method which would be gen- 
erally understood. Thus, the first letter of the Latin name of the part 
excised followed by the sign minus might be tattooed on the skin 
near the initial incision : e.g., A — would show that the appendix had 
been removed, R — that nephrectomy had been performed, etc. The 
presence of scars may lead the obducent to think of herpes zoster, 
cupping, smallpox, chicken-pox, various skin diseases, as acne and 
syphilis, explosions, setons, certain occupations, previous application 
of croton oil, leeches, etc. 



1 The writer once desired to secure for a friend some fresh testicular tissue, and 
hurried to a recent suicide for the purpose of obtaining the testes. Finding scars 
on the scrotum, but no testicles, it was learned on investigation that these organs 
had been removed several years previously, and the young man, being in love, had 
hung himself because he felt that, being thus mutilated, he ought not to marry. 



EXAMINATION OF THE EXTERIOR OF THE BODY 6q 

Scars made by the hypodermic needle in persons addicted to the 
use of morphine are usually found on the arms and thighs, — i.e., in 
those situations which are hidden by the clothes and yet are easily 
accessible to the individual. Small abscesses containing pus are often 
present in these cases. Hypodermic injections by physicians shortly 
before death are usually made over the deltoid muscles or the breast, 
this region being selected owing to the quickness with which the drug- 
is here absorbed into the general circulation. The puncture may be 
surrounded by an elevated white or reddish area similar to that pro- 
duced by the application of cups. Recent saline injections (dermo- 
clysis) also leave marks upon the skin. Exploratory punctures made 
by physicians at times end disastrously, as two of the several cases 
seen by me demonstrated. In one the trocar had penetrated the lung 
and given rise to abscesses which resulted in death. In the other case 
the exploratory needle used in searching for right-sided pleural fluid 
penetrated the liver and caused fatal hemorrhage. 

Much discussion has arisen in regard to the means at our command 
for distinguishing a wound inflicted before and one made after death, 
and as to which is the fatal injury where there are more than one 
wound. On these and similar questions I have heard experts testify 
in court in a manner utterly unsupported by the facts of the case, and 
in a manner they would not do if talking before their county medical 
society. Great caution should, therefore, be used in the expression 
of dogmatic statements concerning such findings. Any blood found 
on the body should be accounted for and all bruises, injuries, etc., accu- 
rately located and described so as to be intelligible to the lay mind. 
In cases of death by electricity the points of entrance and exit of the 
current ought to be carefully sought for, and the shoes should be 
examined for the burns in the leather which are usually seen near the 
nails in the heels. In one of my eight cases of death from electricity 
a man carrying an umbrella with a steel handle, while looking into a 
shop, made connection with the arc light above the window and died 
instantly from the current thus transmitted. 

Parchment-like spots are often seen on the body where the epi- 
dermis has been robbed of its protecting epithelium. Such areas are 
due to the drying of the part, and if produced during life there will 
usually be some ecchymotic spots around them. When seen about the 
mouth, they may have been caused by such agents as strong acids 
(especially carbolic) and alkalies. 

5 



66 POST-MORTEM EXAMINATIONS 

The drawn-up and wrinkled appearance of the skin known as 
" goose-flesh," or cutis anserina, excoriation of fingers, mud, sand, 
water plants, etc., under the nails and in the hands, mouth, nostrils, 
and ears are especially conspicuous after drowning. 

Note the presence of bed-sores and blisters, remembering that 
scalds found on dead bodies are sometimes due to carelessness in the 
use of hot- water bags or bottles during the final illness. 

The region of the neck should be carefully inspected for finger 
markings, scratches, rope markings, etc. The neck should be rotated 
so as to ascertain if a fracture or a dislocation exists. In infants a 
sucking gland is found in each cheek. Cysts may be due to occlusion 
of the salivary glands. 

Enlarged glands can be seen or palpated ; they become conspicuous 
in cases of tuberculosis, leukaemia, cancer, etc. An enlarged thyroid 
should be measured and examined. A slight enlargement of this 
gland is often seen in pregnant women and women at term, the hyper- 
trophy disappearing during the puerperium. Percussion may reveal 
a pleurisy, extensive infiltration of a new growth in the mediastinum, 
an ileocsecal abscess, ascites, enlarged organs, as a spleen or liver, etc. 
The presence of gall-stones or of an hydatid cyst may at times be 
elicited by manipulation. 

Ascites can sometimes be detected by an elevation of the umbilicus, 
the finger being used to depress the part. Echinococcus cysts, encap- 
sulated peritonitic exudates, ovarian cysts, primary carcinoma, and 
allantoic cysts of the urachus may all be found at the navel. 

Deformities. — The body should now be carefully examined from 
head to foot and from left to right, and any variations from the normal, 
either bony or muscular, minutely described. Deformities may be 
congenital or acquired, single or multiple, symmetrical or asymmet- 
rical. Babes 1 believes that there is a special centre, situated in the 
anterior base of the skull in the upper part of the face, which presides 
over the development of the limbs, and that disease of this region 
produces a tendency to the formation of symmetrical deformities. 

Congenital Deformities. — These may be due to embryologic de- 
fects or to traumatic or pathologic intra-uterine causes. Injury during 
delivery is responsible for quite a number of these cases, Allis recently 
advocating that congenital dislocations of the hip are produced at the 

1 Berliner klin. Wchnschr., 1904, vol. xli, no. 18. 



EXAMINATION OF THE EXTERIOR OF THE BODY 6" 

time of birth. Those interested in the pathology of congenital dis- 
location of the hip will find an excellent illustrated article on this 
subject by Carl Ludloff, in Klinisches Jahrbuch, 1902, vol. x, no. 1. 
According to Hirst and Pier sol, the most common monsters are : 

I. Single Monsters : ( 1 ) Autositic Monsters. — Ectromelus, 
aborted or imperfectly formed limbs; symelus, a union of two limbs 
and imperfectly developed pelvis; celosomia, body cleft with some 
eventration, and with anomalies of limbs and genito-urinary apparatus ; 
exencephalus, a foetus with malformed brain, part at least without 
cranium ; pseudencephalus, bones of vault absent or very rudimentary 
and brain rudimentary ; mouth a mere opening ; anencephalus, a foetus 
without a cranium or brain; cyclocephalus, a union of the eyes, gen- 
erally with an absence of the nose; otocephalus, lower jaw wanting; 
ears approach each other. (2) Omphalosite Monsters. — Paraccpha- 
lus, imperfect extremities ; imperfect head and face ; lungs absent or 
rudimentary; heart often absent; one member of a unioval twin, sex 
feminine; acephalus, complete absence of head and upper extremities, 
rudimentary or absent heart, lungs, etc. ; asomata, trunkless head, 
which is not well formed ; no cord ; anideus, shapeless mass covered 
with skin. 

II. Double Monsters : Double Autositic Monsters. — (1) Terata 
Katadidyma : Metapagus, two foetuses united by their cephalic ex- 
tremities ; pygopagus, two foetuses united in the region of the buttock ; 
ischiopagus, two foetuses united by the pelves, coccyges, and sacra, 
with a common umbilicus ; dicephalus, with two distinct heads, usually 
separate necks; diprosopas, having a double face, body single. (2) 
Terata Anadidyma : Dipygus, double pelvis, lower extremities, and 
genitalia: syncephalus, division up to navel and imperfectly formed 
up to head; craniopagus, bodies joined at homologous parts of the 
cranium. Laloo was an illustration of a Dipygus parasiticus. (3) 
Terata Anakatadidyma : Prosopothoracopagus, twins united by the 
thorax, abdomen, and face; omphalopagus, united from umbilicus to 
xiphoid cartilage; rhachipagus, united at the vertebral column. The 
Siamese Twins were examples of monsters of the xiphopagus variety- 
Ill. Triple Monsters. In composite monsters there is a com- 
plete or partial union of two or more foetuses. 

IV. Double Parasites : heterotyphus, a parasitic foetus hanging 
from the anterior abdominal wall of the principal; heteralius, a para- 
site inserted at a distance from the umbilicus of its host and having no 



68 POST-MORTEM EXAMINATIONS 

direct connection with the latter's cord; polygnathus, ill-developed 
fetal parts joined to jaw of autosite; polymelus, duplication of lower 
extremities; endocyma, the greater part of the parasite within the 
body of the autosite. 

Spina bifida is a defect in the union of the laminae of one or more 
vertebrae, with more or less malformation of the spinal cord or its 
membranes. While spina bifida usually shows itself posteriorly, it 
may do so entirely alone or in combination with an anterior opening, 
and. at times, with increase of size due to the presence of a lipomatous 
mass. Euccplialoccle is a hernia of the brain, and meningocele a her- 
nial protrusion of the meninges. 

Various other defects and lesions may be found : as, e.g., complete 
or partial absence of the nose; imperforate ala nasi ; deviation of the 
septum, various abnormal shapes, as saddle-back in hereditary syphilis. 
Palate, cleft. Cheeks, fissures and fistulae. Ears, absence of the helix ; 
haematoma. Mouth, imperforate, abnormally large (macrostoma), 
abnormally small (microstoma). Atresia oris, besides being con- 
genital, may be due to cicatrization from burns. Tongue, absent; 
cleft; atrophied (microglossus) ; hypertrophied (macroglossus) ; or it 
may be adherent to the palate. The fraenum may be too short or too 
long. Alveolar process, absent; cleft; atrophied; hypertrophied. 
Lips, cleft (harelip) ; cysts. Neck, tracheal fistula; cysts on visceral 
clefts. Fingers and toes, absent; atrophied; hypertrophied; super- 
numerary ; webbed ; or clubbed. Sternum, absent, malformed, or fis- 
sured. Ribs, cervical ribs and various defects in their development. 
Umbilicus, skin insertion of the cord; abnormalities of the vessels; 
hernia. Urachus, persists and remains patent. Bladder, extroversion. 
Penis, the glans may be atrophied, hypertrophied, or phimosis or 
atresia may be present; often imperfectly formed in cretins. The 
entire penis may be absent, but this condition may be due to amputa- 
tion, traumatic or pathologic, in which case the scar will be present. 
Scars on glans or prepuce are usually syphilitic. An elongated or 
fissured penis is often associated with calculi. Epispadias or hypo- 
spadia^ may exist. The penis may be found erected after death by 
hanging, injury to spinal cord, or drowning. It may be affected with 
gangrene or cancer, and the arteries may show arteriosclerosis, the 
latter condition being rare. Testicles, one or both may be absent from 
the scrotum or from the body altogether; they may not have de- 
scended, presenting the condition of undescended testicle, or may be 



EXAMINATION OF THE EXTERIOR OF THE BODY 69 

found in some abnormal position. There may be atrophy ; hypoplasia, 
a condition often present in imbeciles; hypertrophy, congenital or 
acquired, or compensatory in one testis, as after the removal or de- 
struction of its fellow; duplication or malformation. Abdominal, 
crural, cruroscrotal, or ilio-abdominal ectopia may occur. These organs 
are usually retracted in cases of drowning. Scrotum, absent, atro- 
phied, or hypertrophied; gangrenous lymphangitis is seen sometimes 
in children. The hypertrophied condition may be acquired, as in 
elephantiasis. Other conditions may be cleft scrotum, hydrocele, 
hematocele, varicocele, and hernia. It may be contracted in cases of 
drowning. Vulva, absent; imperforate; atrophied; hypertrophied. 
The Bartholinian glands may become enlarged, forming retention 
cysts; abscesses; tumors, as fibroma, chondroma, lipoma, sarcoma, 
carcinoma, and myoma. Aphthae occur as white spots on the mucous 
membrane; elephantiasis; herpes progenitalis ; diphtheritic ulcers; 
acne; eczema, especially on the skin of the labia, the vulva, or the 
nymphae, sometimes giving rise to atresia or stenosis ; lupus ; syphilis, 
as the chancre, mucous patch, or gumma; gonorrhoea, as a purulent 
vulvitis; chancroid; and venereal warts are found. Injuries are 
common after parturition and rape. Haematoma, rupture of varicose 
veins, lacerations, oedema, etc., are seen. Clitoris, absent; atrophied; 
hypertrophied, in which case it may simulate hermaphrodism ; car- 
cinoma. Anus, absent or imperforate, or may end in a blind sac. 
Fissures, indurated and irregular. Small polypoid growths may fringe 
the borders. All lesions around the anus are at times altered by the 
distortion of the part with the cotton introduced by those who have 
had the body in charge. Rectum, prolapsed. This condition is com- 
mon in children. The rectum may contain congenital polypi ; internal 
or external hemorrhoids. Fistulas, internal or external, complete or 
incomplete, follow abscesses. Hymen, absent; imperforate; fimbri- 
cated. Its absence may be due to traumatic causes or rupture during 
menstruation. An ovary may lie in the canal of Nuck. Urethra, 
absent or occluded ; atresia or partial phimosis. It may have abnormal 
openings, as on the penis, scrotum, perineum, clitoris, or rectum ; in 
the last case forming a urethrorectal fistula. It may be cleft, present- 
ing a condition of epispadias or hypospadias. It may be inflamed 
(urethritis), with or without Gonococci, and showing a bloody, muco- 
purulent, purulent, or altered spermatic discharge. Chronic, urethritis 
occurs with thickening of the tube. It may be torn by the passage of a 



70 POST-MORTEM EXAMINATIONS 

Stone or foreign body. Stricture may occur, in the male, as a rule, 
four to six inches from the meatus. Tuberculosis is extremely rare. 
Tumors, as fibroma, angioma, sarcoma, epithelioma, are seen. Con- 
dyloma or caruncle may be found. 

Congenital hypertrophies may be confined to the big toe, and are, 
as a rule, associated with disturbances of the genitalia or a persisting 
thymus gland. In rare instances the enlargement is general, as in 
giantism, a condition not uncommonly acquired, when it is apt to be 
irregular and partial, affecting usually the bones of the face and skull 
I leontiasis ossea). Although appearing soon after birth, it more 
often arises at puberty and is due to an abnormal proliferation of the 
cartilages in the process of endochondral ossification. Acromegaly, a 
condition due to some lesion of the pituitary body, is often a cause of 
giant growth, the enlargement affecting the face bones and the distal 
ends of the long bones. Local hypertrophies due to inflammation and 
rhachitis are not at all uncommon. Rokitansky describes deposits of 
phosphates and salts of lime in the cranial and pelvic bones of pregnant 
women ; these are the analogues of the " plaques choriales" of sheep, 
which probably contribute to the development of the fetal skeleton. 

The opposite condition, atrophy, is much more common. The 
general congenital form is the microsomic dwarf (normal proportion), 
a rare condition, the stunting more often affecting only one part, and 
being due to ischsemia or inflammation in utero. It may affect a 
limb (agenesis), skull (microcephalus), pelvis, etc. Acquired micro- 
somia (cretinism, etc.) is the result of absence or disease of the thyroid 
gland, which produces an arrest of development in the longitudinal 
growth of the cartilaginous bones and in the lateral growth of the 
membranous bones. Rhachitis and synostoses are other causes of 
stunted development. Partial atrophy, if congenital, is often confined 
to the head, tibia, fibula, or radius, and is, as a rule, associated with 
other deformity. There may be an entire absence of bones or parts, 
as in apodia, or the lack of a clavicle, scapula, or radius. 

Signs of Degeneration. — Closely connected with malformations 
are the signs of degeneration, as misshaped ears and nose, asymmet- 
rical face, deformed fingers, and some anomalies of the penis, vulva, 
and anus, which should be noted for their statistical value. 

Fractures, — Deformities due to fractures are very common. 
Their character depends upon the location, the bones broken, and the 
age of the fracture. A recent fracture will exhibit crepitus, swelling, 



EXAMINATION OF THE EXTERIOR OF THE BODY y 1 

increased mobility, and deformity due to contracture of the muscles ; 
this contracture, however, may disappear post mortem. If the fracture 
is old there may be non-union, false union, union with deformity, 
false joint or a non-absorbed callus. Deformity due to fracture of 
the shaft of a bone can be more easily found by making comparisons 
between the same bones on both sides of the body, as the femora, 
humeri, and tibiae. Likewise comparisons should be made between 
similar joints, especially the shoulder, elbow, hip, knee, and finger 
joints, to determine whether the deformity be a fracture or a dislo- 
cation. Fractures and dislocations of the neck are frequently over- 
looked, owing to lack of careful examination of these parts. 

Dislocations. — Dislocations are also common sources of deform- 
ity. They may be: (i) Congenital, as illustrated in club-foot. (2) 
Traumatic, resulting from direct or indirect violence or muscular 
action, are the dislocations commonly met with. (3) Pathologic dis- 
locations, due to degenerative changes in the joint, as occurs in tabes 
and Charcot's joint. Recent dislocations rarely show inflammatory 
changes, whereas older ones present evidences that such changes have 
occurred. Contractures are caused by nervous diseases, cicatrices with 
loss of skin and subjacent tissue, burns, and other accidents. These 
contractures are occasionally due to spontaneous dislocations. In old 
traumatic cases ankylosis is sometimes present. Ankylosis also occurs 
in pathologic conditions. 

It may be important to examine the hyoid bone and laryngeal 
cartilages for fracture, dislocation, or laceration. In a case recently 
tried in the New York courts a patient was supposed to have received 
harsh treatment from an attendant in one of the hospitals there. The 
case hinged on determining whether a fracture of the hyoid bone had 
or had not been produced during life. 

Pathologic Deformities. — Such distortions are due to diseases which 
may produce certain changes in the bone structure. The most com- 
mon of these disorders are rickets, tuberculosis, syphilis, osteomalacia, 
acromegaly, and osteitis deformans. Rhachitis is a general cause of 
many varieties of deformity. In this disease the bones lose their 
tenacity and hardness, change in consistency (usually being thickened 
and spongy), and become distorted by the action of the muscles. 
These processes produce certain deformities: (1) Of the extremities, 
bow-leg (genu varum or extrorsum), knock-knee (genu valgum). 
(2) Of the sternum and ribs, pigeon-breast (pectus carinatum), 



POST-MORTEM EXAMINATIONS 

funnel-breast, Harrison's groove, beaded ribs. (3) Of the cranium, 
the square-box rhachitic skull, in the bones of which may be found 
spots of craniotabes. (4) The subject may be more or less dwarfed. 
These arc the most common malformations. 

Tuberculosis is often associated with a long, narrow chest, and is 
a s< uirce of common deformities, seen in coxalgia, Pott's disease, knee- 
joint disease (hydrops articuli), and the various grades of spinal 
curvature. Syphilis in its secondary and tertiary periods may produce 
nodes or cause great destruction of bone tissue. This process is 
present whether the malady be of the inherited or acquired variety. 
Osteomalacia causes bone softening, which may be followed by various 
deformities, especially fracture. This disease usually occurs in women 
after pregnancy. Osteitis deformans also produces changes in bones, 
usually those of the extremities. Certain chronic lung conditions 
result in contraction of one side of the chest and often a corresponding 
scoliosis ; emphysema of the lungs is accompanied by a barrel-shaped 
chest ; nervous diseases lead to more or less disfigurement of the 
body, as facial paralysis and spastic paraplegia; pernicious anaemia 
may either cause or be associated with spinal deformities; pleurisy 
may give rise to unilateral enlargement of the chest; aneurism may 
produce protrusion of the sternum. (For a further discussion of the 
changes found in bones and joints, see Chapter XVII.) 

Tumors and other abnormal growths are also a common source of 
marked deformity. While deformities of the bones are the most fre- 
quent and conspicuous, yet there are other acquired deformities which 
are quite important. Congenital fissures of the neck which are tubular 
and go to the thyroid cartilage and the tuberculous perianal fissures 
should be followed out by careful dissection to their point of origin. 

Muscular Deformities. — These are most generally due to muscular 
weakness. They may coexist with bone deformities and even cause or 
be caused by them ; as deviation of the spine due to bone deformity 
destroys the harmony between the dimensions of the bones and the 
muscles, some muscles become elongated and others shortened. 

Acquired Deformities. — Nature itself may produce deformities, as 
those arising from age, habits, and occupations. Notwithstanding 
that person- assume particular positions most constantly in certain 
occupations, they do not often acquire deformities. 

Tophi. — These deposits occur in gouty persons, and are generally 
found in and about joint-cavities, ligaments, tendon-sheaths, aryte- 



EXAMINATION OF THE EXTERIOR OF THE BODY 

noids, epiglottis, vocal cords, skin of the penis, helix of the ear, tarsal 
cartilages, and margins of the eyelids. They contain a urate and a 
bitirate. both of which dissolve in either acetic or nitric acid and give 
the murexid test for uric acid. If large and advanced they leave a 
white chalk-line when rubbed. Superficial tophi are movable and 
the skin over them is non-adherent, but as the process advances the 
mass adheres and may finally protrude. They are easily differentiated 
from sebaceous cysts. 

Hernia. — Hernia being of common occurrence and a frequent 
cause of death, the various situations where this defect may occur 
must be thoroughly inspected. The abdomen, inguinal canals, fem- 
oral openings, and umbilical region should be carefully palpated. The 
scrotum should be examined to determine the absence of one or both 
testicles, and when these are not found search for them should be made 
in the canal and elsewhere. 

Eyes. 1 — Inquire whether the eyes and mouth were open or closed 
when death occurred, and whether the expression was peaceful or the 
countenance distorted. While in life expression is manifested mostly 
by the eyes and the action of the facial muscles, in death the eyes lose 
their lustre and fail largely to influence the expression. 

Abnormalities. — The eyes should be carefully examined in every 
postmortem, as abnormalities are quite common. The eyelids may 
be wholly or completely absent. They may not be divided or a fissure 
may exist involving one or both lids. There may be eversion or 
inversion. Ptosis, either acquired or congenital, may be present; if 
acquired, it may be due to specific causes. One or both eyes may have 
been replaced by artificial ones. The eye sometimes appears intact 
where sight had been absent for years before death, in which case 
there is always evidence that blindness existed. Abnormal prominence 
is usually caused by cavernous aneurism or exophthalmic goitre; the 
former may be associated with arteriosclerosis, the latter with enlarge- 
ment of the thyroid gland. The presence of puffiness about the eyelids 
should be noted, as it occurs in Blight's disease, cardiac affections, 
arsenic poisoning, and traumatism. 

Position. — Instead of presenting parallel visual axes, one or both 
eyes may be deviated inward, outward, downward, or upward, con- 



1 Much interesting material on this subject will be found in the Pathology of 
the Rye, 1904, by J. Herbert Parsoxs. 



74 POST-MORTEM EXAMINATIONS 

Stituting one of the various types of strabismus, a condition which may 
aid in the diagnosis of toxic, cerebral, or nervous disorders. Conju- 
gate deviation of the eyes occurs in apoplexy. 

Color, — The color of the eyes is due to a blending of factors, vary- 
ing in value in every case, depending largely upon the quantity of 
pigment present. The several races have, as a rule, characteristic 
colored eves: the negroes and the Mongolians, black; the Austra- 
lians and southern European races, dark; the Slavs, the Teutons, and 
the Scandinavians, blue. These peculiarities are worthy of note, as 
they may be of importance for purposes of future identification. 

Conjunctiva. — Whitish patches, which may be congenital or ac- 
quired, are occasionally seen on the conjunctiva. If congenital they 
may be associated with moles on the face. The conjunctiva may be 
the seat of inflammatory conditions, which may be local or associated 
with some systemic disease. To note the variety of conjunctivitis 
present is of some importance, and if any of the severe forms should 
be suspected an effort should be made to ascertain whether or not it is 
specific. Ecchymosis of the mucous membrane may occur in cases 
of injury to various parts of the eye, traumatic conditions affecting the 
skull, dura, or brain, and even systemic disease itself. The conjunctiva 
is one of the seats of jaundice, and it is the place where jaundice shows 
itself most plainly in the negro. 

Pupils. — Accommodation, convergence, and exposure to light, 
which during life produce alterations in the size of the pupils, after 
death do not affect it. In life, age, the color of the iris, and the char- 
acter of the refraction also influence it. Under ordinary circumstances 
the pupils should be equal, but variations may occur, depending upon 
the conditions and cause of death, a few of which will be here men- 
tioned. In fatalities due to chloroform the pupils may remain en- 
larged; in opium poisoning they often expand shortly before or after 
death ; and in cerebral hemorrhage they are generally irregular, 
depending upon the location of the clot. The pupil can be measured 
approximately by holding in front of it a rule marked in millimetres 
and noting the number of spaces its width occupies. This method is 
somewhat fault}- and only approximately measures the width of the 
eye, but an accurate measurement can be made with the pupillometer. 

Cornea. — Note should be taken of the condition, curvature, and 
transparency of the cornea. Keratitis, ulcerations, and abscesses are 
common diseases of this locality. In old persons the arcus senilis is 



EXAMINATION OF THE EXTERIOR OF THE BODY yr 

usually present. Besides its liability to disease, the cornea may be 
lacerated, torn, or injured, with or without the lodgement of foreign 
bodies. 

Sclera. — Examine its surface as to continuity and describe any 
lacerations or injury which it may have received. 

Iris. — The iris should be inspected for color, condition, and quan- 
tity of pigment. As this is a common seat of disease and operations, 
it should be especially examined for the presence of a coloboma, one 
of its most common malformations, which may be either congenital 
or acquired. The congenital form is due to the failure of the ocular 
fissure to unite ; it may he distinguished by the presence of the sphinc- 
ter, which in the acquired form has been excised along the margin of 
the coloboma, as after an iridectomy. The fissure is usually situated 
in the lower part of the iris, and is often associated with coloboma of 
the choroid. The iris should also be examined for the scars of opera- 
tions, for the information thus obtained is of value. 

Crystalline Lens. — Luxation or subluxation of the lens should be 
looked for. If present it may be either congenital or acquired. 
Coloboma of the lens is accompanied by a similar condition of the 
choroid or iris. 

Optic Nerve. — This portion of the eye together with the retina can 
best be examined with the ophthalmoscope. 

Growths. — The most common growths of the eye and the parts 
generally affected are: Iris: angioma, metastatic sarcoma, usually 
from the ciliary body, granulomata, and cysts. Choroid : sarcoma, 
most common of all tumors, metastatic carcinoma, occasionally found, 
nsevus, rare, cysts, rare. Ciliary body : sarcoma, common, adenoma, 
occasional, carcinoma, occasional, nsevus, cysts. Retina : glioma and 
cysts. 

Meningocele and hernise of the brain containing cerebrospinal fluid 
may be found protruding from the sinuses into the orbit. Dermoids 
of the orbit are frequently discovered, especially near the eyebrows; 
those of the eye occur at the corneoscleral junction. The so-called 
carcinoma originating from the lachrymal gland is usually an adeno- 
sarcoma. Lipoma of the eye, which may be either congenital or 
acquired, occurs in the fatty tissue. Tumors originating from the 
bone are generally sarcomas or exostoses. 

Orbital Injuries. — As injuries are frequently received in and about 
the orbit, careful examination of this region should be made. Frac- 



- n POST-MORTEM EXAMINATIONS 

uircs through the orbit may cause, besides serious damage to the eye 
itself, grave cerebral complications. 

Orbital Diseases. — Diseases of the orbit are quite common and 
may be important, for they often cause meningitis. Caries, necrosis, 
and cellulitis are generally preceded by periostitis. 

After thorough examination of the eyes they should be carefully 
closed. 

1 [air. — Examination of the hair may prove, especially in medico- 
legal practice, to be of importance. Not only the hair on the cadaver 
but also any hair found in the immediate vicinity of the body should 
be examined. Hair not belonging to the corpse demands inquiry as 
to whose it was and whence it came. In this way observations of 
value have been made and aided greatly in unravelling some of the 
world's deepest mysteries. The hair varies in color, length, quality, 
and quantity in different individuals, and also according to situation 
on the same person. The head of the new-born infant is covered 
with fine downy hair, a growth of the last two or three months of 
intra-uterine life. Shortly after birth it is shed and replaced by the 
true hair. The hair is one of the last tissues to yield to decay. The 
question of the growth of hair after death is a disputed one. Such 
apparent growth is most frequently caused by the retraction of the fat. 
In the new-born there is no medullary canal in the hair. (Vibert. ) 
Human hair can be positively identified as such. 

Color. — The color of the hair should be noted and described; also 
observe whether or not the color is uniform. As it depends mostly 
upon pigment, the color will vary in proportion to the quantity and 
variety of that pigment. Gray hair in adults is attributed to a diminu- 
tion in pigment, and may be due to age, care, mental worry, sudden 
fright, burns, local inflammations, systemic diseases, nervous disturb- 
ances, hardships, or exposure to cold, as seen in Arctic explorers. 
Gray hair in the infant is congenital. Abnormal whiteness of the hair 
is a condition found in albinos. It may be complete or partial and is 
associated with loss of pigment in other organs. The examiner should 
not he misled by dyes. 

Length. — The length of the hair should be observed and approxi- 
mately measured. Long or short hair is characteristic of sex and of 
certain races. The longest hair is seen in the Indian, Chinese, and 
Malay; short hair in the Negro. 

Quality. — Various races have hair of characteristic texture. The 



EXAMINATION OF THE EXTERIOR OF THE BODY yy 

Negro and the Bushmen have crisp, woolly hair: among the Anglo- 
Saxon, Germanic, and kindred races the hair is smooth ; Australians 
have soft, smooth, wavy hair; the American Indian has coarse hair. 

Quantity and Distribution. — Hairs normally may be present on all 
exterior parts of the human body., except the palms of the hands, soles 
of the feet, glans penis, mucous membranes, and the ball of the eye. 
Some races are prone to excessive hair growth, as the " hairy men'' 
of the Island of Yesso. Loss of hair, complete or partial, may be due 
to depilatories, pregnancy, disease, or pressure. Baldness or moth- 
eaten appearance of the head, eyebrows, and moustache is seen in lues 
and myxcedema. Epileptic, idiotic, and insane persons generally have 
large growths of hair. Abnormalities of distribution have been re- 
corded, and the examiner may often find either absence or overgrowth 
in certain localities. Under these conditions hair may be found in the 
interior of organs and neoplasms, especially ovarian dermoid cysts. 

Diseases. — The hair of the body is subject to various diseases, and 
therefore its condition should be carefully noted. Various forms of 
alopecia, tinea, and fungi may attack the hair. These conditions may 
be due to local or constitutional disorders. 

Injuries and Tumors. — Located under the hair tumors and various 
injuries may be present. Therefore pass the fingers through the hair 
of the scalp, and if it be at all thick part it, which aids in the discovery 
of wounds, haematomata, and tumors which it may conceal. Should 
any be discovered, cut or shave the hair so as to examine them more 
carefully. If the head has been injured, it will usually be found that 
the hair has already been removed by the surgeon. 

Nails. — When examining the nails attention should be paid to 
the material found under them, as it quite frequently is of medico- 
legal importance. The growth of the nail is regarded as one of the 
diagnostic signs of fetal maturity. 

Anomalies. — The nails may be absent, atrophied, hypertrophied, 
brittle, discolored, cracked, etc. Congenital absence of one or more 
nails is usually associated with other malformations. Acquired anony- 
chia may be due to trauma, nervous diseases, pyogenic infections, scar- 
leaving affections, as syphilis, and blood-stasis, as in cyanotic condi- 
tions. Another anomaly often met with is imperfect nail formation, 
resulting from dystrophia, in which the nail is usually opaque, dis- 
colored, brittle, and fissured. Certain diseases are sometimes noticed 
about the nails, as abscess, eczema, psoriasis, paronychia, syphilis, and 



-S POST-MORTEM EXAMINATIONS 

professional dermatitis with paronychia. Traumatism confined to the 
nail or surrounding tissues is frequently met with and its nature and 
extent should he noted. 

Teeth. — The teeth should be examined as to anomalies, condition, 
and disease. 

Anomalies. — One or more teeth may be permanently absent, or 
supernumerary teeth may be present to such an extent that there are 
two dental arches in either one or both jaws. The teeth may be 
irregularly placed, often beyond the alveolar process. In examining 
the teeth notice should be taken of the condition of the palatal arch. 

Condition. — Much can be learned from the condition of the teeth, 
as to care, neglect, habits, and disease. The teeth should be examined 
to see whether they are artificial. It is a noticeable fact that people 
from certain countries have particularly fine teeth regardless of the 
care taken of them. Caries of the teeth and the extent to which it 
involves the bone should be noted and, if possible, the cause deter- 
mined. Among other conditions phosphorous poisoning produces 
necrosis of the teeth and maxilla. Hutchinson's teeth are frequently 
seen and the condition is one of considerable importance. It consists 
in a single deep notch of the permanent upper central incisors, but 
the deformity is sometimes present in the molars when it is absent in 
the incisors. Dental tumors, such as epulis, sarcoma, osteoma, odon- 
tomata, or dentigerous cysts, are occasionally found. 



CHAPTER VI 

TECHNIC OF OPENING THE ABDOMINAL CAVITY AND THE TOPOGRAPHIC 
EXAMINATION OF THE PARTS CONTAINED THEREIN 

After the completion of the external examination of the body, all 
necessary instruments are placed in order upon a board or tray, 1 and 
the operative part of the autopsy is begun. 

The operator should stand so that when facing the body the in- 
cisions from above downward can be made with the greatest ease. 
This condition is best fulfilled by right-handed operators standing on 
the right side of the supine object, and left-handed operators on the 
left side. The body should be drawn well to the side of the table 
nearest the operator, the head resting on the top of the table and, if 
preferred, the shoulders supported by a block. 

With the knife held in the manner previously described (page 
36), as nearly horizontal as possible, a clean incision (Fig. 54) 
should be made by a single sweep of the arm from the interclavicular 
notch (A) to the symphysis pubis (B), passing to the left of the 
umbilicus (C) in order to avoid the round ligament and any vessels 
going to and from the navel, care being taken not to penetrate the 
abdominal cavity and thus injure the contained viscera, or to extend 
the incision to the external genitalia so as to disfigure them (Figs. 
57 and 58). On the chest this primary incision goes down to the 
sternum, whereas on the abdomen it penetrates only to the muscle- 
sheath. In Europe the initial incision is usually made at the middle 
of the chin, — i.e., starting at the symphysis menti and ending at the 
symphysis pubis; for there, as a rule, only the poor who die in the 
hospitals reach the post-mortem table, autopsies being seldom per- 
formed on the bodies of prsons belonging to the upper classes, who 
would naturally object to the disfigurement entailed by this method. 
In this country the longer incision should be used only when great 
haste is necessary, as in cases of contagious diseases, such as diphtheria, 

1 A towel may be laid over the external genital organs and the upper parts of 
the thighs, upon which the instruments to be used in the performance of the autopsy 
are placed, with their handles towards the obducent. An ordinary stool is frequently 
used abroad for this purpose. 

79 



8o POST-MORTEM EXAMINATIONS 

or when the body is not to be seen again by relatives or friends. If 
the mentopubic incision be employed, it should not injure the thyroid 
gland, the omohyoid being the only muscle to be cut through. The 
knife now follows underneath the skin, fat, and fascia along the lower 
border of the inferior maxillary bone, until the digastric muscle and 
the submaxillary gland are seen. The gland is then incised, the 
muscles being left in situ. The common carotid artery, internal 
jugular vein, and pneumogastric nerve are now readily exposed. Care 
should be taken to avoid wounding the vein, as the resulting hemor- 
rhage hinders subsequent manipulations; such injury is especially to 
be guarded against on the left side in those cases where search is to be 
made for the entrance of the thoracic duct into the subclavian vein. 

The initial incision over the thorax is now carried down to the 
sternum in any place where this has not already been done, and the 
layers of skin, fascia, and muscles of the right side are quickly dis- 
sected away close to the ribs, freely exposing the costochondral articu- 
lation and some three inches of the sternal end of the clavicle. To do 
this the attachments of the soft tissues are made tense by drawing 
them away from the median line with the left hand (Figs. 59 and 
60), while long sweeping incisions are being made downward and 
laterally with the large section-knife. The left side may next be simi- 
larly treated, though in practice this is more frequently done after 
the abdominal incision has been completed. Some permit an assistant 
to prepare the left side while the operator is uncovering the right, but 
the time saved by this procedure is small and the danger of injury to 
those taking part is great. 

Should a pneumothorax have been diagnosed during life, the 
thoracic pocket made by elevating the skin-flap on the side of the 
pneumothorax is filled with water, and a puncture is made at the 
bottom through the costal pleura at the intercostal space between the 
sixth and seventh ribs at the axillary line. If a pneumothorax be 
present, bubbles of air will escape through the water, the visible supply 
of which will rapidly diminish. If the head be lowered and enough 
water be used, this will finally escape from the mouth. It should be 
remembered, however, that a cavity in the lung opened accidentally 
by the knife would give the same result as that arising from a pneumo- 
thorax. 

A note is now made as to the situation and character of any blood 
which may escape. The condition of the fat (panniculus adiposus) 




Fig. 143. — Lines for removing the spinal cord and the brain, the latter 
through a small triangular occipital incision. A B, initial incision for 
removal of the cord; CD, curved incision for the purpose of avoiding 
division of the skin above the dressed portion of the body ; E A F, angular 
incision in the occipital bone through which to remove the brain without 
elsewhere opening the skull. 




I C 








u *"' ■v '• 









JSI. 



3 « 
O 

•r <u 

• rt ■£ .i 



"Sill 

£ -5 <« o 
s H o a 
a bo 3 

' s > 'I si 




Fig. 57.— Method of making the initial incision over the sternum, as seen from ahove. 




-The same incision as in Fig. 57 somewhat extended, as Been from ' 




FlG. ^9.— Method of raising flap on right side so as to expose sternum and ribs, as seen from above. 




Fig. 60. — Same incision as in Fig. 59, seen from the side. 



g 2 | 





TECHNIC OF OPENING THE ABDOMINAL CAVITY gl 

is considered, and its thickness noted at the nipple-line, beneath the 
xiphoid, and again three inches below the umbilicus. In atrophy the 
color of the fat becomes darker, changing to orange or reddish yellow. 
As a rule, the older the individual the darker in color is the fat, varying 
from straw-color in children to the dark yellow seen later on in life. 
Different species of animals have different colored fat, depending upon 
the difference in its chemical composition. The tissues here are often 
oedematous, as in general dropsy or erysipelas. 

The mammary glands may now be examined from behind, and, 
if desired, the glands of the axillae may be exposed by continuing the 
dissection of the pectoral muscles from beneath. After the reflection 
of tissue over the ribs, the mammary gland on each side may be 
opened by four or five parallel perpendicular incisions, followed by 
several transverse ones, if deemed necessary. When the gland is 
quiescent, it will be found to consist of dense, whitish, fibroid tissue, 
in which are a few pin-point, grayish-red spots (breast-grains). 
During lactation it is larger, and the secreting tissue grayish red in 
color and granular, looking like a salivary gland. (Orth.) Fibrous 
tissue is found only near the nipple. Pressure may cause an outflow of 
a yellowish creamy colostrum (which is not altogether unlike pus in 
its appearance) ; this should be at once examined under a low power 
of the microscope. The following conditions of the gland should be 
thought of : 

i. Deformities: (a) depressed nipple; (&) mamma infantilis (hy- 
poplasia) ; (c) supernumerary glands or nipples. (2) Congestions 
and anaemias. (3) Burns. (4) Inflammations: (a) inflammation of 
nipple; (b) fissures; (c) mastitis, acute; (d) abscess of connective 
tissue: («) between skin and mamma; (£) between muscle and 
mamma; (r ) acini and ducts, (e) Fistula: («.) soft edge may 
mean milk fistula; (P) indurated edge may mean mammary abscess; 
( r ) if broken and caseous, it is more likely tuberculous. (5) Granu- 
lomata, gummata, tuberculosis, caries of ribs. (6) Changes of nutri- 
tion. Remember in this connection that tumors of the genitalia or 
pseudopregnancy may cause an hypertrophy of the gland with a true 
secretion of milk, and that a similar result may occur in rare cases in 
the male apparently from certain psychic influences. (7) Tumors, 
fibroma, carcinoma, echinococcus cysts, etc. 

The muscles now to be examined are those of the neck, chest, and 
abdomen. The external examination notes any marked changes in 

6 



82 POST-MORTEM EXAMINATIONS 

bulk. Both a transverse and a longitudinal section are necessary 
to a complete study, and the general characteristics should be observed. 
The muscles may be atrophied or hypertrophied. Trophic change 
induced by affections of the anterior horns of the spinal cord may show 
itself in muscular atrophy and may be either inflammatory or degen- 
erative, as in infantile paralysis, progressive muscular atrophy, and 
amyotrophic lateral sclerosis. The lesions may chiefly affect the pe- 
ripheral and intermuscular nerves, as in lead paralysis with atrophy 
and in certain atrophies following diphtheria and other exanthemata, 
or the muscles may be primarily affected, as in the juvenile form of 
Krb's paralysis and pseudohypertrophic paralysis, or reflexly, as in the 
Charcot joint-affections. (Dreschfeld.) Hypertrophy due to exercise 
increases the number of muscle-cells ; when due to an increased blood- 
supply, the individual fibres are increased in size. Muscle is a highly 
organized tissue, and as such does not reproduce itself with ease after 
injury. 

As the color of a muscle is due to haemoglobin or some modification 
of it, its appearance will vary according to the state of the blood. 
Normally muscle is a bright red, but in anaemia it becomes paler, at 
times a grayish red. In general it may be said that the color and con- 
sistence of the muscles bear a distinct relation to each other : pale 
muscles are usually soft, while the darker muscles are more firm. 
The muscles are dry when much fluid has been carried off by the 
alimentary canal, as in typhus fever and cholera, and moist after the 
occurrence of disturbances of the circulation. Zenker in 1864 de- 
scribed a form of colloid degeneration resembling the flesh of fish in 
the flat muscles of the abdominal walls, occurring especially in enteric 
fever, though found in tetanus, scarlet fever, smallpox, and near 
sarcomatous tissue. In diseases where the muscles have long been 
inactive, a similar grayish translucent appearance is at times observed. 
The dark meat of the fowl undergoes decomposition sooner than the 
white. The flesh of different animals possesses characteristic odors. 
Embalming fluids containing zinc bleach the muscles, while arsenic 
preserves their natural color. Formalin hardens them. 

The general characteristics having been observed, the pathologic 
conditions to which these muscles are subject are not liable to escape 
detection. The more important morbid lesions are : 

( 1 ) Hemorrhages. — These may result from trauma, wet cups, 
hypodermic injections, etc. The outflow from the cut veins often 



TECHNIC OF OPENING THE ABDOMINAL CAVITY g. 

gives a good idea as to the color, fluidity, and odor of the blood. 
A special form of bleeding into the rectus may occur in typhoid fever, 
the so-called " hematoma recti abdominis.'' 

(2) Inflammations.— Among these are included: (a) Acute 
Myositis. — This is often suppurative, and may be primary, from 
trauma, or more usually secondary, in the muscles of the chest, to 
pleural affections, or, in the muscles of the abdomen, to pelvic suppu- 
ration. This inflammation does not, as a rule, produce true abscesses, 
but infiltrations in the muscle and separation of its fibres, which 
undergo a fatty or hyaline degeneration. Hematogenous inflamma- 
tion is by no means uncommon, perfect examples of miliary tubercles 
often being found if searched for in suitable cases. (/;) Chronic Myo- 
sitis. — The interstitial connective tissue is increased so that at times it 
is visible to the naked eye, the muscle-fibres are atrophied, the color 
becomes a grayish red, and the muscles feel solid. This condition is 
generally associated with diseased states of the neighboring parts, — 
e.g., affections of the ribs,- pleurae, cervical glands, etc. There is a 
syphilitic form of fibroid myositis. Glanders and actinomycosis may 
affect the muscles. (c) Parenchymatous -Myositis. — The muscle is 
paler than normal. All the various forms of degeneration — as cloudy 
swelling, hyaline or fatty — affect muscle, and microscopic examina- 
tion, as in acute primary polymyositis, is necessary in order to deter- 
mine their presence, (d) Bony formations are sometimes found, as 
the " drill" bones in the shoulder muscles and the " riders" bones in 
the adductors of the thigh. (Ziegler. ) Progressive ossifying myositis 
is a rare disease, running a chronic course, which especially attacks 
young people; those thus affected are sometimes exhibited in dime 
museums as " petrifying" persons. 

(3) Parasites. — The most important parasite is the Trichina 
spiralis, which is found most frequently in the muscles of the neck and 
in the intercostals near the attachment of the diaphragm, and in old 
cases the calcified capsules may be easily recognized as small, white, 
oval bodies, which when present in large numbers look and feel like 
grains of sand. In the muscle itself the site of election is close to the 
spot where the tendon unites with the muscle proper. In order to 
the parasite the capsule should be dissolved with hydrochloric acid. In 
its early stages the animal is not readily discovered, and its detect inn 
is made easier by pressing a teased portion of muscle between two 
glass slides and observing it by transmitted light with a hand [1 



84 POST-MORTEM EXAMINATIONS 

In all doubtful cases the aid of the microscope should be evoked. 
Measles and hydatids may also be found in the muscles. 

(4) Tumors. — Primary tumors are rare; they usually originate 
from the connective-tissue septa. 

The abdominal cut is now deepened between the umbilicus and 
the xiphoid cartilage until a small portion of the peritoneum is ex- 
posed. 1 This membrane should then be carefully opened and if it be 
desired to determine the presence and character of any gas present in 
the abdominal cavity, the incision is made down to the peritoneum, 
either two inches above or the same distance below the umbilicus, and 
the abdominal walls are elevated with the fingers or a tenaculum so as. 
to form a pouch, into which water is poured. A test-tube is then filled 
with water and inverted over the pouch, and a small incision is made 
through the peritoneum under the mouth of the test-tube so as to 
allow any gas escaping to go into it. The test-tube is tightly closed 
before all the liquid has run out of it, by pressing a thumb or finger 
up against its mouth, and placed in a shallow dish containing sufficient 
water or mercury to seal the open end of the tube. It is then handed 
to the chemist for examination. If a lighted match be held close to 
the point where a knife is pushed into the chest, any gas escaping de- 
flects the flame. It should be remembered that certain gas-forming 
organisms may be the cause of the gaseous collection in serous cavities. 
The recent discovery of hitherto unknown elements in the air makes 
the study of aggregation of gases here an extremely interesting one. 
If the gas has an acid odor, an opening in the stomach is to be suspected. 

If fluid be present, the abdomen usually protrudes, the sides are 
flattened, and the superficial veins much dilated, a caput Medusae form- 
ing about the umbilicus. Ballottement will often reveal its presence, 
and when found a mental note should be made carefully to examine 
the oesophageal veins, as a fatal hemorrhage may occur from their 
rupture, a fact which I have more than once personally substantiated 
post mortem. In ascites just enough of the fluid should be removed 
to facilitate the determination of the height and location of the dia- 
phragm, which may be done by introducing the hand, palm upward, 
or a steel sound, into the abdominal cavity and following the under 
surface of this muscle as far as possible. When the tips of the fingers 
or the end of the sound reach the point of least resistance, this spot 

1 For the technic of a bacteriologic examination see Chapter XXIII. 



TECHNIC OF OPENING THE ABDOMINAL CAVITY g^ 

should be sought for with the other hand from without. The vault 
of the diaphragm extends to the fifth rib on the left side and to the 
fourth rib or fourth interspace on the right. Both sides are measured 
in the line of junction of the ribs with the costal cartilages. The greater 
height on the right is due to the liver, which forces the diaphragm 
upward, and in excessive hypertrophy may cause it to reach even as 
high as the level of the second rib. Increase in the abdominal contents, 
as by tumors, pregnancy, hypertrophy of the spleen, etc., elevates the 
diaphragm, while augmentation of the thoracic contents natural Iv 
pushes it downward. Along with the depression is a sense of fluctua- 
tion in cases of hydro- or pyothorax. The position of the diaphragm 
in a new-born child helps to determine whether or not it has breathed. 
Before respiration has occurred, the summit is found on a level with 
the fourth rib on the right side and on a level with the fifth rib or the 
fourth intercostal space on the left. After full expansion of the lungs 
has taken place, the summit is found at the fifth or sixth rib on the 
right and at the sixth rib on the left ( Orth ) . 

The opening may now be somewhat enlarged and additional fluid 
removed with a syringe, cup, or large pipette, measured, and its char- 
acter noted. The remaining portion may be collected from the various 
folds and pouches in the peritoneum with a sponge or small cup. The 
amount of fluid normally present is very small, not usually exceeding 
a teaspoonful ; it may be lemon-yellow, red, or brown ; icteroid or 
milky; watery, thick, gruel-like, or even semisolid. The removal of 
liquid at this stage of the operation prevents its admixture with blood, 
as from an accidental incision into the liver while cutting the costal 
cartilages, or with other fluids of the body, such as those from the 
pericardium, the pleura, the bladder, or various portions of the intes- 
tinal tract. Ascites is especially associated with Bright's disease, 
chronic heart disease, chronic lung disease, anaemia, portal obstructiori 
due to cirrhosis of the liver, chronic passive congestion of the liver, 
inflammatory adhesions, etc., tumors, displaced or hypertrophied vis- 
cera, as the enlarged spleen of malaria or leukaemia, and peritonitis, 
especially when tuberculous. The serous membrane is apt to be lustre- 
less, whitened, and thickened, especially the capsules of the spleen and 
liver, if the disease has lasted any length of time. The intestines are 
frequently matted together by fibrous adhesions, and the uterus and 
adnexa often show a similar condition, especially when the peritonitis 
is of a tuberculous nature. 



86 POST-MORTEM EXAMINATIONS 

In cases of increased amount of fluid it is of importance to dis- 
tinguish between a serous transudate and an inflammatory exudate. 
When large amounts of pus and fibrin are present, the differentiation 
is easy, as a transudate contains neither. Difficulty arises when a 
clear watery fluid is found in which minute flocculi are seen, as these 
may be either small Hakes of fibrin and pus-cells or collections of 
washed-off endothelial cells. The differential points are as follows : 

Transudate. Exudate. 

Fluid clear and watery, though it may Fluid thick, ropy, and at times foul 

form a spontaneous clot. smelling. 

Alkaline reaction. Acid reaction. 

Flocculi are thin, veil-like, and of a Flocculi are thick, opaque, and of a 

transparent gray color. grayish-white color. 

Specific gravity usually below 1016. Specific gravity generally over 1016. 

Albumin usually below two per cent. Albumin may exceed three per cent. 
No bacteria or their products present. Contains organisms, toxins, globuli- 

cides, etc. 
Urea * and cryoscopic index low. Urea and cryoscopic index high. 

Under the microscope the flocculi are Microscope shows the flocculi to con- 
seen to be made up of flat cells with sist of fine threads and polynuclear 
large nuclei and lymphocytes. leucocytes, the nuclei of which ap- 

pear more distinctly on the addition 
of acetic acid. 

Milky exudates are of two kinds, fatty and chylous. The former 
excretion has been found in connection with peritoneal and mesenteric 
cancer, and is recognized by the fat-globules seen on microscopic ex- 
amination. Slight amounts may be due to the fact that the patient 
was on a milk diet or was suffering from lipaemia, a dyscrasia also 
found in diabetes (Osier). A chylous exudate results from the per- 
foration of the thoracic duct or the receptaculum chyli. 

Suppurative exudates, due to perforation of the intestine, are thick, 
yellowish, and contain much fibrin, which is deposited on the perito- 
neum and bowel in layers. The odor, which is peculiarly nauseating, 
may be due to the Bacillus coli communis; the process is usually acute. 

A hemorrhagic exudate or fluid may be non-inflammatory, as 
that arising from trauma (rupture of the liver or spleen or extra- 
uterine pregnancy), from cirrhosis of the liver, from cancerous and 
tuberculous peritonitis, etc., or it may be inflammatory. Pure bile, 
most frequently mixed with blood, may be found in the abdominal 
cavity after injury to the gall-bladder or the bile-ducts. 



1 Ulrici, Centralbl. f. innere Med., no. 16, 1903. 



TECHNIC OF OPENING THE ABDOMINAL CAVITY gy 

One finger is now introduced into the opening previously made 
in the abdominal cavity, the flap of the skin is elevated, and the incision 
is somewhat lengthened. Next the index and middle fingers of the 
left hand, held V-shaped (Fig. 61). palm upward, are thrust under 
the abdominal wall in oider to raise it above the intestines so as to 
prevent injury to them in the subsequent incision, the fingers acting as 
a director while the cut is continued to the pubes. Then a similar 
incision is made up towards the xiphoid cartilage. If there be much 
meteorism, the index-finger of the left hand can be introduced and 
held against the parietal peritoneum. If scissors be used, the lower 
blade may be guarded by the fingers of the left hand when the cut is 
made. Another method is to make the incision while the part is well 
elevated above the intestine by strong traction upward on the right 
abdominal flap. The cutting should preferably be done from within 
outward, great care being taken not to puncture or injure any of the 
abdominal viscera, especially the stomach and bladder. After noting 
the location and distribution of adhesions as pointing to previous 
inflammatory conditions, it is well to break up such adhesions with 
the fingers. Should the intestine be accidentally opened, it is best to 
stop at once and tie both above and below the opening in order to pre- 
vent the escape of the contents of the bowel into the peritoneal cavity. 

If it be desirable to enlarge the opening in the abdominal wall 
(Fig. 54), a second incision (D E) may be made, at right angles to 
the first one and about three inches above the umbilicus, or the rectus 
muscle on one or both sides of the body may be divided subcutaneously 
a little above Poupart's ligament (F and G) . Should there be a pene- 
trating wound of the abdomen, as from a dagger or a previous celiot- 
omy, the abdominal incision may be changed at will (Figs. 55 and 56). 

When the contents of the stomach are found in the peritoneal 
cavity, care must be taken to determine whether their escape was due 
(a) to post-mortem digestion, or autopepsia, (b) to trauma, (c) to 
perforation from a gastric ulcer or from chemical erosion of the coats 
of the stomach by poisons, etc., (d) to the presence of (h) and (<>. 
with the factor (a) as the real cause. In the first case the ingesta are 
usually widely distributed throughout the abdominal cavity, though 
most plentifully in the immediate neighborhood of the perforation, 
the rent is large and irregular, and the walls are soft and slimy; while 
in disease the opening is apt to be small and circular and surrounded 
by evidences of hemorrhage and peritonitis. Undigested food enters 



88 POST-MORTEM EXAMINATIONS 

the peritoneal cavity through a breach in the gastric wall; when 
digested food or faeces are present, the seat of injury is the bowel or 
duodenum, and, if the latter, the material is usually stained with bile. 
Autodigestion is especially frequent in cachectic children. Intestinal 
worms may escape into the peritoneal cavity through perforations in 
the bowel. From the fact that the autopsy is usually performed a 
considerable time after death, the appearances presented by a gastric 
ulcer are slightly different from those seen at an operation during life, 
for the serous wall of the ulcer may have undergone a certain amount 
of post-mortem digestion. 

The suspensory ligament of the liver may be studied at this time. 
Should there be an omphalomesenteric duct, it should be carefully 
followed out to its diverticulum in the ileum. 

Foreign bodies, which may be calcified, are sometimes found free 
in the abdominal cavity; they are derived from torn-off appendices 
epiploicae or polypoid tumors. Surgical instruments and appliances, 
such as sponges, artery-forceps, scissors, and gauze compresses, have 
been discovered in the abdomen after the performance of operations, 
v. Neugebauer 1 citing 195 such instances. In Europe severe punish- 
ment has been meted out to surgeons for their forgetfulness in this 
respect. 

The abdominal cavity being thoroughly exposed, the most striking 
abnormalities therein are to be noted. Transposition of the viscera 
would at once be observed. The most marked displacements of abdomi- 
nal organs seen by the writer were in cases of Pott's disease and 
diaphragmatic hernias. 

The omentum ordinarily comes first under observation. Normally 
the omentum is non-adherent to the intestines except at its point pf 
attachment ; in purulent peritonitis it may be markedly adherent to 
the peritoneum covering the intestinal tract, creamy or plastic lymph 
appearing in streaks throughout its structure. The omentum may 
form a part of every variety of hernia found in the abdomen ; it may 
be present alone in the hernial sac, or the intestines may become 
strangulated by passing through an opening in it. Trauma or atrophy 
of the connective tissue may produce such openings, some of which 
may be of large size. The amount of fat deposited between the layers 
of the omentum varies considerably, being in some cases practically 

1 Ccntralb. f. Gyndkologie, 1903, vol. xxvii, no. 8. 



TECHNIC OF OPENING THE ABDOMINAL CAVITY go 

absent and in others measuring as much as half an inch in thickness. 
During health the omentum is rich in fat, which disappears early and 
rapidly in emaciation. Normally the layers are readily separable, and 
when spread out form a beautiful thin, transparent membrane, with 
irregular deposits of fat, and showing the blood-vessels partly filled 
with blood. It is a common seat of fat necrosis, tuberculosis, and 
generalized cancer ; in the last two conditions it may be so contracted 
upon the transverse colon or the greater curvature of the stomach 
as to be hardly visible, and separable therefrom only with the greatest 
difficulty. Enlarged glands, encysted parasites, infarcts, pins, super- 
numerary spleens, etc., may be found. 

The serous covering of the stomach and intestines should be 
minutely inspected, as the play of colors is very varied and the infor- 
mation gained from this examination is often of great importance. In 
thrombosis of the mesenteric vessels the gut may be gangrenous for 
ten feet or more. Miliary tubercles are found opposite tuberculous 
ulcers and extend along the lymphatics ; they are also seen on all the 
other portions of the peritoneum, often being wide-spread in tuber- 
culous peritonitis. Small yellowish, creamy collections of lymph, with 
dilated lymphatics, are seen if death occurred several hours after eat- 
ing; these are physiologic and not pathologic products, but I have 
known them to be mistaken for miliary tubercles and even for carci- 
nomatous growths. The presence of typhoid ulcers may be recognized 
by a congested area along the length of the intestine. The location 
of the vermiform appendix should always be noted, and Virchow's 
dictum (first published in 1875, though practised long previously) 
should be remembered : " At least in every case of inflammation of the 
peritoneum the appendix is to be carefully examined." In the female 
an inspection should be made of the uterus and its adnexa. The 
mesenteric glands, especially those near the ileocsecal valves, are to be 
carefully looked at; they are greatly enlarged in typhoid fever, in 
which they sometimes undergo suppuration, and in children dying 
from inanition, where they appear as red nodes, often running together 
into conglomerate masses. 

The transverse colon may assume odd shapes and positions; thus, 
it may be bent like the letter U and extend as low as the bladder; it 
may or may not drag down the stomach. In some cases ii forms 
peculiar S-shaped curves; in others the hepatic and splenic flexures 
may be markedly deficient. These malpositions are supposed by some 



QO POST-MORTEM EXAMINATIONS 

to be especially common in the insane. Cotton which lias been inserted 
m the rectum or vagina by the nurse or undertaker to prevent the 
escape of fecal or other matter may be mistaken for a foreign body 
and may possibly have caused displacement of neighboring parts. 

The stomach is subject to marked changes in size and situation, 
as from hour-glass contracture, tumors, ulcerations, etc. In the babe 
its situation is nearly vertical. This viscus is often filled with gas 
formed after death ; a peculiar sound may sometimes be heard when 
the gas is expelled by pressure from without. One does not realize 
the extent to which the stomach may be distended by food and drink 
until he has made post-mortem examinations of the viscera of inebriates 
and persons accidentally killed soon after they had eaten hearty meals. 
The capacity of the stomach may be estimated by filling it with water 
and measuring the amount; but the method is not accurate and may 
destroy the appearance later on of a gastric ulcer. 

All the openings in which hernise are apt to occur are next to be 
examined, the most common varieties being inguinal hernia in the 
male and femoral and umbilical hernise in the female. Other forms 
of rupture are those into the canal of Nuck, the obturator foramen, 
or the sciatic notch ; into the various fossae about the caecum or the 
fossa jejunalis; into new fossae formed by bands of adhesions, as 
from extra-uterine pregnancy; from solutions of continuity in the 
mesentery; crural; diaphragmatic, which is often congenital, but 
may. be due to traumatism; between the rectus muscles and through 
Petit's triangle ; after operations, especially those on the appendix, etc. 

Volvulus and invagination are not infrequently seen. True in- 
vagination is to be distinguished from a form which often occurs in 
children just previous to death ; in the latter cases multiple lesions 
I sometimes as many as fifteen or twenty), produced during the agonal 
period, are found. There is a peculiar form of invagination in which 
the ileocecal valve draws the ileum down into the caput coli; this 
condition when extreme may even cause the ileocaecal valve to appear 
at the anus. Philipowiez J finds that volvulus of the sigmoid occurred 
in one-third of all such cases reported. 

Note if the gall-bladder is distended or contracted; see if it 
extends below the liver, and, if so, to what extent. Feel it gently and 
note if any gall-stones are contained therein. Should a bacteriologic 

1 Arch. f. klin. Chir., 1903, vol. lxx, nos. 3 and 4. 



TECHXIC OF OPENING THE ABDOMINAL CAVITY g L 

examination of this part be wanted, it is now to be made. Follow 
with the hand the upper surface of the liver, first of the right lobe 
and then of the left, in order to determine their extent, noting- the 
height and the distance to which they extend below the ribs. The tips 
of the right and left lobes of a large liver almost meet at the vertebral 
column. The left lobe may extend downward like a beaver's tail, and 
as a result of tight lacing the whole organ may be divided into an 
upper and a lower portion by bands of connective tissue containing 
the biliary vessels and a few liver-cells. Extra lobes are very common ; 
some of them even take the form of supernumerary livers. This con- 
dition may be congenital, but it is more frequently due to syphilis. 
In one of my syphilitic cases the liver was made up of more than thirty 
lobes, in shape resembling a bunch of flattened and distorted hydatid 
cysts. The liver should next be slightly raised, the pylorus examined, 
and the tips of the fingers used to determine the presence of calculi in 
the bile-ducts and *gall-bladder. 

When no extensive pathologic lesions exist, the situation of the 
pancreas may readily be determined by remembering' the close connec- 
tion of its head with the concavity of the duodenum. 

During this superficial examination of the abdominal cavity any 
needful departure from the ordinary routine may be planned. Thus, 
in a case of cancer of the head of the pancreas it may be advisable 
later on to remove this organ along with the stomach, the duodenum, 
or even the liver. Again, in the case of a child or when there is not 
time for a careful dissection, all the organs of the abdominal cavity 
may be removed en masse. One must always be on the lookout for 
supernumerary organs, for they occur in the most unexpected places, 
as pulmonary tissue below the diaphragm, adrenal tissue in the liver, 
and pancreatic tissue on the wall of the stomach. 

To repeat, the relative positions of all the tissues should be observed 
and any departure from the normal noted, and a careful search made 
for foreign growths, attachments, anomalies, etc.. none of the parts 
being at this time removed from the body or their relations so dis- 
turbed as to prevent further examination. 



CHAPTER VII 

TECH NIC OF EXPOSING THE THORACIC CAVITY AND THE CRITICAL 
EXAMINATION OF THE PARTS CONTAINED THEREIN 

Method of Opening the Thorax. — After the superficial ex- 
amination of the parts contained in the abdomen, the organs of the 
thoracic cavity may be exposed to view in the following manner. The 
second to the tenth costal cartilages on the left side are cut through, 
one by one, from above downward, at a point close to the attachments 
of the osseous portions of the ribs. For this purpose a heavy cartilage- 
knife is employed, which should be held as nearly parallel to the chest 
surface as possible, so that as the blade cuts through one cartilage it 
strikes the next one, thus preventing injury to the organs beneath. 
In order that the knife may not be dulled by this procedure, the cutting 
may be done by the part of the blade near the handle. Or the knife 
may be introduced into the intercostal space beneath the rib that is 
about to be cut, using the next lower rib as a fulcrum and cutting from 
within outward (Fig. 62). As the incision proceeds downward the 
ribs are severed more and more towards the axillary line, thus making 
the opening in the chest larger and larger. In cases where the carti- 
lages are calcified it may be best to use a costotome or a saw for their 
division, in which event the ribs might as well be cut outside the costo- 
chondral junction in order to allow more room for subsequent manipu- 
lations. The second to the tenth ribs on the right side are now severed 
in a similar manner. 

The right clavicle is next separated from the sternum. As its 
head articulates with the latter bone and the cartilage of the first rib, 
the collar-bone is grasped with the left hand and its inner end is 
moved to and fro, or an assistant may produce the same result by 
moving the whole arm. In this way the line of articulation is easily 
made out, and permits the part to be disarticulated by cutting down- 
ward and slightly outward until the first rib is reached (Fig. 63), 
thence continuing the incision outward along the under border of the 
clavicle and the upper part of the first rib for at least two inches. The 
first rib, which is generally calcified, is next cut through with a knife 
92 




Fig. 65. — Method of incising the first rib and the sternoclavicular articulation with the costotome. 




Fig. 66.— All the ribs of the right side have been severed, the sternoclavicular attachment to the first 
rib remaining intact on the left side. The lower portion of the sternum is elevated and ti;i< tion made on 
the diaphragm, which is cut as close as possible to the lower border of the sternum. 




Fig. 67.— The lower border of the sternum having been freed, the breastplate is elevated and pulled 
upward and towards the left. The left sternoclavicular attachment is thus easily discovered, and is cut 
through. The first rib is then detached. Care is especially taken on this side not to injure the subcla- 
vian vein, not only on account of the blood escaping upon adjacent parts, but also owing to the difficulty 
after disturbance of the parts in finding the entrance of the thoracic duct into the vein. 




Fig. 68.— The sternum is here practically ready to be removed from the body. The knife is cutting 
any attachments which may not previously have been severed in the neighborhood of the left sterno- 
clavicular articulation. 







— -. -a a a 
5 ~L. - ° <2. 





Fig. 71.— Method of opening pericardium. The left hand supports the right flap of the pericardial 
sac. while the knife cuts the pericardium up to its attachment to the great vessels coming off from the 
heart. 




FlG. 75.— Method of removing the heart from the body. The index-finger is placed in the left ven- 
tricle and the thumb in the right ventricle, and the ventricular septum is grasped. The heart is then 
raised upward and towards the chin, placing on a stretch the blood-vessels which enter the heart. 
These are cut, starting with the lower pulmonary vein and going from left to right in a circular direction 
until the upper pulmonary veins are reached, or the initial incision may be made at the inferior vena cava 
and cud with the pulmonary veins. 



TECHXIC OF EXPOSING THE THORACIC CAVITY q. 

from below outward or from above inward (Fig. 64). Or the cos- 
totome may be employed for this purpose (Fig. 65). 

The next procedure is accomplished by making traction on the 
breastplate upward and towards the right. Beginning below on the 
left side and keeping close to the lower border of the sternum, 
the underlying tissues, diaphragm, and mediastinum are cut through 
with short transverse strokes of the knife (Fig. 66), the sternum 
being elevated more and more as the tissues are separated. All 
the lower attachments having been cut and care having been taken 
not to open the pericardium, the breastplate is now elevated and any 
uncut tissues of the mediastinum and of the right side are incised. 
The elevated sternum is now to be pulled towards the left. Any 
sternocostoclavicular attachments on this side being made tense are 
easily discovered and severed, the knife passing along and beneath the 
upper part of the sternum (Fig. 67). The increased room and the 
greater leverage afforded by torsion of the sternum upon the left 
sternocostoclavicular attachment make this part easier of removal 
than on the right side. The tissues made tense by raising the sternum 
are divided, the bone being pushed more and more to the left and 
slightly rotated. The right first rib is cut through and the left clavicle 
is now disarticulated from below (Fig. 68). This procedure usually 
requires very little use of the knife, the force applied by the rotation 
often being sufficient for this purpose. The breastplate, after its 
removal from the body, is shown in Fig. 69. If an aneurism or tumor 
be found adherent to the ribs or sternum, its point of attachment is 
preserved by sawing through the bone at some distance therefrom. 

In removing the sternum great care is necessary in order to avoid 
cutting the innominate or internal mammary veins which lie beneath 
its upper end and the clavicle. In Bavaria and Wiirttemberg, in order 
that these vessels may not be injured and the part bathed with blood, 
the regulations for the performance of medicolegal autopsies direct 
that the lower end of the sternum, when freed, shall be strongly ele- 
vated, and the sternoclavicular connection and the first rib cut from 
the under side, or the breast-bone may be sawed through below the 
attachment of the first rib, leaving it and the sternoclavicular articula- 
tion intact. The writer does not approve of the method often used, 
after cutting the ribs, of breaking the sternum by turning it backward 
just below the clavicular attachment. Though it avoids injuring the 
veins, it leaves an ugly place from which to receive scratches and d 



94 POST-MORTEM EXAMINATIONS 

not give as much room for the subsequent examination of the thoracic 
cavity and neck. Some careless operators do not even remove the 
hone, but while still attached turn it back over the face. Do not forget 
to return the sternum to its proper place in the restoration of the thorax, 
an error often made and not discovered until the body is sewed up. 

In order to protect the hands of the operator from future injury, 
the skin daps are now wound around and beneath the exposed clavicle 
and ribs (Fig. 70), or these may be covered with a strip of antiseptic 
gauze held in place by a stitch around an upper and lower rib. Cotton 
should not be used for this purpose, as portions become detached and 
become adherent to the tissues of the body, thus interfering with future 
manipulations. 

Sternum and Ribs. — The examination of the sternum and ribs 
may now be undertaken. Their shape is often altered, as in Pott's 
disease, pigeon-breast, emphysema, perforated sternum, rickets, occu- 
pation deformities, such as pressure atrophy in shoemakers, caused by 
holding the shoe against the breast, etc. Tuberculous caries of the 
sternum, often secondary to caseation of the mediastinal lymph-glands, 
or metastatic tumors may be present, or an aneurism may cause press- 
ure atrophy (erosion) or even perforation of this bone. It is this 
form of saccular aneurism which is now treated by wiring and by 
electrolysis. Fracture is not common, but may occur between the 
second and third costal cartilages, — i.e., near the junction of the manu- 
brium with the gladiolus. The ensiform appendix of the sternum is 
m nnetimes curled upward and outward like a hook in cases of hepatic 
hypertrophy or tumor. Where this condition is present with atrophic 
cirrhosis of the liver, it indicates a previous enlargement of that organ 
(Suchard). The marrow of the sternum (best exposed by a longi- 
tudinal opening), which is normally of a slightly reddish, lymphoid 
appearance, may present the changes characteristic of leukaemia, 
anaemia, tuberculosis, etc. In the last stages of carcinoma the sternum 
and ribs are at times so infiltrated with cancerous deposits, especially 
when the breast is affected, as to break readily. The ribs may show 
evidence of rhachitis by the presence of the rhachitic rosary, in which 
case a section of the rounded enlargements, especially where the carti- 
lage joins the bones, will show the changes peculiar to rickets. In 
old persons the entire cartilage may be calcified or even ossified. The 
central substance of the ribs sometimes undergoes atrophy and absorp- 
tion, leaving a large canal filled with blood. The cartilage may contain 



TECHNIC OF EXPOSING THE THORACIC CAVITY () - 

cystic cavities. Coplin has recently shown that the intercostal muscles 
are apt to show dissociation of fibres, leucocytosis, infiltration, granu- 
larity, etc.. in disorders affecting the lungs and pleura. 

The clavicle may now be freed almost to its acromial attachment, 
the arm extended at a right angle to the body, and the region of the 
subclavian vessels and brachial plexus readily exposed and studied. 
In one of my cases I found that the brachial plexus had been ligated 
by a competent surgeon in mistake for the artery. Should it be 
desired to remove these vessels, the vein may be tied and the whole 
incised beyond this point preparatory to their removal en masse. The 
ending of the thoracic duct on the left side may now be studied, or 
this may be done after the removal of the heart and lungs. 

Mediastinum. — The condition of the mediastinum is to be noted, 
especially as to emphysema in the areolar tissue, tumors, usually sec- 
ondary, the ductus arteriosus, the thymus, and the peribronchial and 
other lymphatic glands. Except in the young the latter are pigmented, 
and for this reason have more than once been mistaken for melanotic 
sarcoma. They are often tuberculous, and may be infiltrated with can- 
cerous or sarcomatous matter. Emphysema is most often produced 
after death by the removal of the sternum during the autopsy or by 
decomposition. When the lung is lacerated, the emphysema is more 
extensive and may even extend into the neck. Hemorrhage into the 
mediastinum may be due to trauma, to phosphorous poisoning, or to 
acute yellow atrophy of the liver. An abscess may be found, or a 
chronic mediastinitis, marked by fibrous thickening and density of the 
connective tissue. The latter usually occurs in conjunction with a 
fibrous pericarditis (mediastino-pericarditis), and is of importance on 
account of its influence upon the heart action (Orth). 

Thymus Gland. — This weighs about 13.75 grammes at birth, 
and increases in size until the end of the second year, when it weighs 
about 26.2 grammes. It then gradually diminishes and after puberty 
is normally absent, though it has been observed in acromegaly, my\ 
oedema, exophthalmic goitre, and many other pathologic conditions. 
The gland should always be sought for, as it is not infrequently presenl 
in the adult, when it is more of a yellow color than the normal 
grayish red. Even when the thymic tissue itself has disappeared, the 
place of its former situation can usually be marie out by the increased 
amount of fibro-adipose tissue. Hemorrhages are often found in die 
thymus glands of stillborn babes. Pus may sometimes be present. 



9 6 



POST-MORTEM EXAMINATIONS 



Abscesses are seen at limes in syphilitic children. Mistakes have been 
caused by the altered appearance of the normal juice after it has under- 
gone post-mortem change; hence great care is necessary in making 
the diagnosis of suppuration. Sudden death in infants may be due 
to pressure symptoms from an unduly enlarged thymus. Sarcoma, 
endothelioma, angioma, and dermoids are found. 

Thyroid and Parathyroid Glands. — Both lobes of the thyroid 
ma}- at this time be examined in situ, or, if preferred, the gland, 
together with the tongue, velum palati, epiglottis, oesophagus, trachea, 
parathyroids, carotids, intercarotid bodies, etc., may be removed in a 
single piece (see page no) and studied subsequently detached from 
the body. The pyramid of the thyroid (Lalouette's pyramid) is a slight 
cone-shaped extension from the upper part of the gland to its point 
of attachment by loose fibrous tissue to the hyoid bone. The thyroid 
body may show enlargement due to parenchymatous or interstitial 
changes, or a combination of both, or associated with hypertrophy of 
the thymus and dilatation and hypertrophy of the heart. The colloid 
material may be considerably increased in amount and deposits of 
lime sometimes occur. Congenital goitre is now and then observed. 
The colloid goitre may become cystic and form cystic adenoma, into 
which hemorrhage might later occur. Thyroiditis is found in some of 
the infectious fevers, as diphtheria. Myxcedematous degeneration, or 
cachexia strumipriva, is due to disease or removal of the gland. In 
cretinism the body is small, the head large, the countenance heavy, 
the abdomen protruding, kyphosis is often present, the lips are thick, 
the skin and mucous membranes dry and pale, and the hair is coarse 
and lustreless. Primary malignant tumors of the thyroid are seen, a 
mixed-celled sarcoma, at times angiomatous, being more common than 
cancer. There may be accessory thyroid glands, as at the base of the 
tongue, where goitre may occur. 

The parathyroid glands, 1 which were discovered by Sandstroem, 
are four in number and are histologically different from the thyroid. 
They are usually unaffected by changes in the thyroid, colloid material 
being only rarely present. The superior parathyroids are situated 
behind the junction of the upper two-thirds with the lower one- third 
of the posterior thyroidal body and near the cricoid cartilages. The 



1 El policlinico, 1902, no. 21, fasc. 3; Ziegler's Beitr'dge, 1902, vol. xxxi, p. 142; 
Vvrchovfs Arcliiv, vol. clxxiv, no. 3. 



TECHXIC OF EXPOSING THE THORACIC CAVITY gy 

inferior group is posterior to the lower part of the thyroidal lobes. 
The parathyroids probably develop from the third and fourth branchial 
clefts, those from the lower cleft eventually becoming the higher ones. 
They are of epithelial structure and furnish an internal secretion. They 
possess duct-like passages, probably analogous to the thyroglossal duct, 
and often become cystic. The parathyroids bear a distinct relation to 
the larger thyroid vessels and their shape varies considerably. As age 
advances the amount of fibrous tissue and fat increases. The vessels 
enter at a slight depression which may be regarded as a hilum. Tumors 
sometimes develop in the parathyroids and their removal may give 
rise to symptoms of myxcedema. Graves's disease is probably due to 
partial aparathyroidism, notwithstanding the fact that the disease is 
benefited by section of the cervical sympathetics. 

Superficial Examination of the Lungs. — The appearance and 
situation of the presenting portions of the lungs are now observed. 
The normal color of the lungs at birth is a pinkish-white; in adult 
life, a dark slate-color, mottled in patches; as age advances this 
mottling may become nearly or quite black, owing to the deposit of 
carbonaceous material. Changes in color may be due to differences in 
the amount and character of the blood present or to some pathologic 
process. When the thorax is opened, the normal lung retracts, on 
account of its own elasticity. This contraction of the lung may not 
occur, because of the absence of elasticity, because of emphysema, 
because of pleural adhesions, because the alveoli are full of solids or 
fluids, the result of inflammation, or because stenosis of the larynx, 
trachea, etc., may prevent the egress of air. In cases of alcoholic 
intoxication and suffocation the lungs are generally found to be mark- 
edly expanded fOrth). 

Xext note the amount of fluid contained in the pleural cavity, 
whether or not it is clear, bloody, turbid, or of an inflammatory nature, 
and whether or not adhesions are present. The remarks made upon 
the peritoneal fluid apply with equal force to that found here and in 
the pericardium. As a practical point it is well to remember that serous 
membranes when normal are barely visible to the naked eye, being 
smooth and glistening, but when inflamed their appearance depend- 
upon the nature of the inflammation; the membrane will then be 
found roughened and more or less opaque, especially if examined by 
an oblique light. The situation and extent of any lesion present should 
be noted. 

7 



9 8 POST-MORTEM EXAMINATIONS 

If for any reason a pneumothorax be suspected, after carefully 
removing - the fluid present, fill the pleural cavity with water and 
inflate the lungs with air by means of an intubation tube connected 
with a pump by a piece of rubber tubing. The rising air bubbles will 
reveal the situation of the laceration in the lung. In examining the 
pleural cavities inspect the left one first. 

Pericardium. — Note the position and condition of the pericar- 
dium, whether or not it is distended with fluid and to what extent it 
is covered by the lungs. When there is much distention of the peri- 
cardial sac, the direction and length of its principal diameters and 
borders — the latter, it should be remembered, are anatomically the 
reverse of those of the heart — should be noted before any fluid is 
allowed to escape. To open the pericardium it should be grasped 
near its centre by the fingers or a tenaculum, and a longitudinal fold 
elevated before it is incised in order to prevent injury to the heart 
and the escape of any excess of fluid which may be present. A small 
incision is then made at the highest point, under strict precautions if 
a bacteriologic examination is to be made, and the fluid present drawn 
of! with a syringe or pipette into a graduated glass and its quantity 
noted. The opening in the pericardial sac may now be enlarged suffi- 
ciently to admit two fingers, which are then spread apart, thus ele- 
vating the pericardium and protecting the heart while the pathologist 
cuts between them. With a knife or a pair of scissors two incisions 
are made — one downward and to the right, the other downward and to 
the left — as far as the diaphragmatic attachment. The right flap is 
then drawn strongly forward away from the heart and another cut is 
made in an upward direction to the point where the pericardium is 
reflected around the vessels coming off from the heart (Fig. yi ). The 
phrenic nerves are now plainly seen on the lateral inner surfaces of the 
pericardium and the anterior portion of the heart is exposed to view. 

Hydropericardium. — Normally there are from one to two teaspoon- 
fuls of clear citron-colored fluid in the pericardial cavity. In certain 
renal, cardiac, and pulmonary diseases this may be increased to several 
pints, the greatest amount being seen in general anasarca. The fluid 
is clear, watery, wine-colored, and may coagulate on standing. The 
serosa is smooth, glossy, and transparent. Later it may become sero- 
fibrinous, hemorrhagic, or purulent. 

Hccmopericardium. — The presence of pure blood in the pericardiac 
sac is usually a sequence of rupture of an* aneurism of the heart or of 



TECHNIC OF EXPOSING THE THORACIC CAVITY gg 

the aorta, trauma, etc. Hemorrhagic exudates may be the result of 
inflammatory diseases, as in cancerous and tuberculous pericarditis, 
rheumatism, of chronic nephritis, of hypertrophy of the heart, etc. In 
the first instance the blood is present in large amounts and is clotted, 
while in the latter case it is derived from newly formed vessels in the 
inflammatory tissue. 

Pneumopericardium. — The presence of air in the pericardial sac 
is nearly always caused by perforation from without, as in cases of 
stab-wounds, though it may be due to openings into the lungs, oesoph- 
agus, or stomach. Or it may be consequent upon decomposition, espe- 
cially of an exudate. Its pathology resembles that of pneumothorax. 

Pericarditis. — The pericardium, normally transparent and glisten- 
ing, may lose its lustre, become rough and hypersemic, and be covered 
with a more or less dry fibrinous exudate. When there is but little 
fluid and abundant exudate, the latter is thrown into villoid projections 
by the movements of the heart, and the characteristic buttered surfaces, 
or cor villosum, may be found. Newly formed granulation tissue may 
follow a fibrinous exudate, with the formation of a productive peri- 
carditis, and the later plastic adherence of the visceral layers of the 
pericardium, thus causing a complete obliteration of the sac. Suppu- 
rative pericarditis shows pus in the sac, and may be the result of 
trauma, or secondary to suppurative mediastinitis, cancer of the ribs, 
extension from pulmonary or pleural affections, or a general infection. 
Minute hemorrhages are seen, with flocculent or curdy collections in 
the dependent parts of the sac, and erosions are sometimes present. 
In some epidemics of pneumonia I have found that pericarditis was the 
immediate cause of death in nearly all the fatal cases. 

Other Lesions. — Cancer, usually secondary, may be met with; in 
a specimen of melanotic sarcoma of the heart and pericardium at the 
laboratory of morbid anatomy in the University of Pennsylvania, the 
lesion was secondary here as well as in the lungs, the diagnosis of 
sarcoma being made by Prof. Guiteras from the discovery of pig- 
mented cells in the sputum. Foreign bodies, gummata, cysticerci, 
echinococci, and trichinae have been described. Tubercles may be seen 
along the course of the vessels or old cheesy tuberculous deposits may 
be found in chronic cases. 

Injuries. — Wounds of the pericardium and heart may be caused 
by stabs, broken ribs, and foreign bodies in the oesophagus. If the 
main axis of the muscle fibres have been cut, the pericardium will be 



LofC. 



IOO POST-MORTEM EXAMINATIONS 

full of blood ; if tbe injury be parallel to its long axis, there may be no 
bleeding- and die wound of the heart may heal spontaneously. 
Suturing of the heart muscle is now a well-recognized surgical pro- 
cedure. Foreign bodies, like bullets, have been found encapsulated in 
heart muscle. 

If an aneurism have been discovered, it is usually best not to 
separate the aorta from the heart, but to remove the aneurismal sac 
and the heart together. The aorta is not to be opened until the heart 
has been examined. In endocarditis vegetations are sometimes present 
in the arch of the aorta, and might easily be overlooked if not espe- 
cially searched for. To discover air emboli, the thoracic cavity is rilled 
with water and the heart opened under water in situ. Gas may arise 
from decomposition of the blood. 

Heart. — The heart is to be observed before it is touched. Its nor- 
mal position may be altered by fluid in the pericardium or in the 
pleurae, by cardiac hypertrophy, in which case the apex may reach to 
the anterior axillary line, or by tumors of the mediastinum. The heart 
is about as large as the right fist. It measures from base to apex from 
85 to 90 millimetres in men and 80 to 85 millimetres in women between 
the ages of twenty and sixty years; its greatest transverse diameter 
varies from 92 to 105 millimetres in men and 85 to 92 millimetres in 
women; it is about 35 or 36 millimetres thick in men, and from 30 to 
35 millimetres in women. Any displacement is determined by the 
situation of the apex and the base, which are anatomically described 
especially in relation to the ribs, sternum, nipples, and median line of 
the body. Cardiac enlargement may be due to heart disease or sec- 
ondary to disorders of the lungs, kidneys, aorta, etc. The color of the 
surface of the heart depends very much upon the condition of the epi- 
cardium and the underlying fat. The auricles, especially when well 
filled, are dark blue, while the color of the ventricles differs with the 
condition of the muscle. The consistence of the various portions of 
the heart depends upon the degree of contraction of its muscular tissue, 
as well as upon the amount and composition of its contents (Orth). 

The contraction (systole) and the relaxation (diastole) of the two 
auricles and the two ventricles are considered in relation to the amount 
of blood contained within them. The amount of blood, especially if it 
be fluid, does not afford a criterion of the quantity therein during life, 
owing to the free communication of the vessels and cavities of the 
heart. After death from asphyxiation the right chambers of the 



TECHXIC OF EXPOSING THE THORACIC CAVITY IOI 

heart are distended with dark fluid blood, while after death from digi- 
talis the left ventricle is contracted. Overfilling of the left ventricle 
is found when death was caused by cardiac paralysis. For bacterio- 
logic examination or chemical analysis the blood is usually taken with 
the sterilized pipette, as described on page 347, from the cavity which 
is most distended by it, unless, of course, for some reason blood from 
a special cavity or side is desired. The circulation of the lymph and its 
deposits should be carefully studied. 

The epicardium and the amount of subepicardial fat are to be care- 
fully observed, as well as milk spots. In cachexia the subpericardial 
fat may be transformed into a soft, transparent, gelatinous mass, which 
becomes whitish on the addition of acetic acid. This is the so-called 
mucoid change of the subepicardial fat. Small lipomata may be found 
near the apex; and small subpericardial ecchymoses — so-called spots 
of Tardieu — are of medicolegal importance, as they are frequent in 
cases of death due to suffocation, particularly in the new-born, but may 
occur in the infectious fevers, as in diphtheria. 

The situation and condition of the coronary arteries should be 
noted, and they, more especially the anterior one (the left), should 
be palpated, to ascertain whether or not they are " pipe-stem" in 
character. The interior is to be examined when they are opened 
later on. The coronary veins are easily distinguished from the ar- 
teries by the relative thinness of their walls as well as by their course. 
Overfilling of the larger veins indicates an obstruction to the outflow 
of blood from the right auricle (suffocation, etc.), unless it be confined 
to the posterior parts, in which case it is due to hypostasis. The large 
opening seen in the superior vena cava just before its entrance into the 
right auricle is the termination of the great azygos vein. 

The interior of the heart is now to be examined, and here again, to 
secure the best results, it is expedient to adhere to a definite plan of 
procedure. There are several so-called " methods" of opening the 
heart, but all have the same object and all accomplish it more or less 
completely, — viz., that of exposing the cavities and valves with the 
least possible interference with the septa and the parts subsequently to 
be examined, and in such a way as to permit of the organs being recon- 
structed, or returned to their original shape and relations. The method 
adopted and described by Virchow for use in the Berlin Charite is 
undoubtedly the best, although the others may, if thoroughly under- 
stood and properly executed, yield very satisfactory results. 



! ; 02 POST-MORTEM EXAMINATIONS 

Ordinarily it is advisable that certain incisions be begun while the 
organ is still in situ and completed after it has been removed from the 
body. As each cavity is opened, careful note should be made of the 
quantity, color, and consistence of the contained blood and of the size 
and character of any clots that may be present. If the opening is 
occupied by a clot, this should be removed. 

Primary Incisions. — After breaking up pericarditic adhesions, if 
present, the heart should be gently rotated on its long axis by slight 
pressure between the index-finger and thumb of the left hand, at the 
same time that slight traction is made downward and to the left of the 
body. This will bring the points of entrance of the superior and in- 
ferior venae cavse into view ; midway between which the first incision 
is begun and then carried downward in the direction of the right ven- 
tricular ridge until the right auriculoventricular septum is reached 
(Fig. 72, A B, and Fig. 77). Next make an incision in the right 
ventricle, just below the auriculoventricular septum, passing down the 
right ventricular ridge to the interventricular septum, which is a little 
to the right of the apex (Fig. 72, CD). On the left side make an 
incision in the auricle, beginning in or slightly below the lowermost 
pulmonary vein and, continuing in the direction of the left ventricular 
ridge as far as the auriculoventricular septum (EF). Open the left 
ventricle along the entire length of the left ventricular ridge, and, as 
this ventricle normally forms the apex of the heart, the incision will 
be carried to and through that point before the ventricular septum is 
reached (Fig. 72, G H, and Fig. 78). This incision must not join 
that of the other ventricle, but should be separated by an interval of 
about one-half inch. From the fact that these incisions are made 
while the heart is still in situ, they may be called primary incisions. 

In cases of sudden death in which an embolus of the pulmonary 
artery is suspected, it is best to open that blood-vessel before re- 
moving the heart. This assures the finding of the embolus, which 
might otherwise be obscured in cutting the pulmonary artery for re- 
moval of the heart. By this method, also, the ductus arteriosus and" 
congenital heart lesions in infants may be investigated. 

Removal of the Heart from the Body. — To remove the heart, 
introduce the index-finger and thumb of the left hand into the left 
and right ventricles respectively, grasp the ventricular septum near 
the apex, and elevate the heart sufficiently to make slight traction 
on the great blood-vessels (Fig. 75). Then, if no aneurism be pres- 



TECHNIC OF EXPOSING THE THORACIC CAVITY IQ3 

ent, sever all the normal attachments as near their point of passage 
through the pericardium as possible, and in the following order, — viz., 
the inferior vena cava, the superior vena cava, the pulmonary artery, 
the aorta, and lastly the pulmonary veins. Avoid injury to the oesopha- 
gus during the removal of the heart from the body. Or, the heart 
is drawn outward preparatory to severing the vessels, as may be soon 
illustrated in Fig. 76. 

Measuring and Testing the Valves. — Immediately upon the re- 
moval of the heart from the body, the blood and clots should be care- 
fully removed from about the valves. The valvular openings are then 
to be measured. Their size is usually estimated by the number of 
ringers that the ostium will admit. Normally the mitral ostium will 
admit the index and middle finger, whereas through the tricuspid open- 
ing the index and middle finger of one hand and the index-finger of the 
other hand can be introduced. This method is, of course, convenient, 
but is very unscientific and inaccurate and should be superseded by the 
use of a constant unit of measure. Graduated cones, or balls of defi- 
nite sizes placed on rods (Figs. 49 and 50), answer the purpose very 
well. They are gently inserted in the direction of the blood-current, 
and the exact size of the opening can then be given in millimetres or 
inches. Vegetations upon the valves may be injured by careless hand- 
ling. An equally scientific method is to measure the attached margins 
and to determine the diameter by dividing by 3.14 ( 71 ). 

The competency of the valves should now be tested. To do this, 
trim the great vessels down so that the valves may be seen. The heart 
is then evenly supported by each of the vessels in turn, — i.e., held in 
air and in such a way that the semilunar valves will be as nearly hori- 
zontal as possible, at the same time receiving no unnatural support 
from beneath. Water or mercury is then to be poured in by a second 
person until the vessel is filled, and note is made of the action of the 
valve. In case no one else is present, the heart is to be held under 
water and then quickly taken out, and the valve being tested observed. 
If there is any leakage from the aorta, make sure that it is not from 
a cut branch of one of the coronary arteries. The best result of the 
water-test is seen in the semilunar valves, the competency of the 
auriculoventricular valves not being accurately determined by this 
method, which has of late rather fallen into disuse. 

Should it be necessary or desirable to ascertain the competency of 
the auriculoventricular valves, the primary incisions above described 



I0 4 POST-MORTEM EXAMINATIONS 

are not made until the heart has been removed from the body, and the 
test is begun by cutting a transverse slice from the apex and exposing 
the ventricles. The heart is now everted and each ventricle is filled 
separately with liquid. This method of removing the organ before 
opening is also useful in examining the heart of a child or when it is 
desired to make a bacteriologic examination of the valves. In the 
latter event no water should previously be used, lest some of the vege- 
tations be washed out or other bacteria than those present be intro- 
duced, thus creating more or less serious confusion. 

Hamilton advises the use of air for testing the competency of the 
valves, and gives the method as follows i 1 " An incision is first made 
into the left auricle, and any post-mortem clots are carefully removed 
from the left chambers through it. Another incision large enough to 
admit the nozzle of a half-inch tube is made into the ventricle near its 
apex and in the line of that required for laying it fully open. The 
tube is joined to a bellows, and air is driven intermittently into the 
ventricle by means of it, the aorta having been meanwhile closed. The 
valve will be seen to open and close, according as the air is aspirated 
or driven out of the bellows. A like procedure is adopted for the dem- 
onstration of the tricuspid. To test the aortic valve, the incision 
before described as necessary to lay open the left ventricle is continued 
up as close to the valve as possible without injuring it. The tube is 
tied into the aorta, and the action of the valve is watched from below. 
The same method is used to test the competency of the pulmonary 
artery valve. As a matter of fact the tricuspid, in the human heart, 
will always be found more or less incompetent." 

Secondary Incisions. — Place or hold the heart with its posterior 
surface downward. This can be told by the situation of the pulmonary 
artery, which is situated anteriorly. Insert a pair of probe-pointed 
scissors or the blade of the enterotome (now a cardiotome) in the in- 
cision in the right ventricle, and cut from the centre of that incision 
through the centre of the attachment of the two anterior leaflets of the 
pulmonary artery (Fig. 73, / J, and Fig. 79). The point of junction 
of the anterior leaflets can usually be seen from the outside, but, if not, 
it can very easily be determined by looking into the vessel or feeling it 
with the index-finger. This incision is to be continued until it opens 
up the entire portion of the pulmonary artery which has been removed 

1 Hamilton, Text-book of Pathology, vol. i, p. 9. 




Fig. 77. — Method of opening the right auricle ; an incision is made down to the auriculoventricular 
septum of the right side. This incision is usually made while the iheart is in situ, but for the sake of 
clearness is here shown as being made outside of the body. 




FlG. 78.— Method of opening left ventricle. The heart is being opened outside of the body. The left 
hand steadies the heart while the knife cuts along the left ventricular ridge, starting just below the 
auriculoventricular septum and ending at the apex. 




Fig. 79.— The pulmonary artery is made tense with the left band, while from the 1 entre oi the right 
ventricular incision the anterior portion of the right ventricle is cut in the direction of the thumb and 
middle finger which mark the junction of the two anterior pulmonary semilunar cusps. 




Fig. s o. — The left auricle and ventricle are fully opened, exposing the 
papillary muscles, endocardium, etc. 



litral valve, chordae tendineae. 




FlG. 8i. -Completed incisions of the heart, the organ having been reconstructed after the examina- 
tion of all its cavities and parts. The coronary artery has not been dissected out. This is done for several 
inches with the scissors, and then transverse incisions may be made with the knife about three-eighths of 
an inch apart as the artery becomes smaller and branches. 



TECHXIC OF EXPOSING THE THORACIC CAVITY io5 

from the body. Some pathologists advise making this incision towards 
the left of the pulmonary artery, so as to cut between the left anterior 
and posterior cusps. The right ventricle is now exposed so that the 
condition of the pulmonary valves, endocardium, myocardium, chordae 
tendineae, etc., of this side of the heart may be noted. Now dissect 
away the connective tissue binding together the pulmonary artery and 
the aorta. 

In opening the left ventricle, cut the anterior wall as near the ven- 
tricular septum as possible, starting from the apical extremity (H) 
and stopping at the point overlapped by the left auricular appendix 
(K). Then, using the cardiotonic, the incision is completed (either 
from the aorta or from the ventricle) by cutting between two leaflets 
(L K). In the aorta there is but one anterior leaflet, consequently the 
incision should be to either one or the other side, but preferably as 
close as possible to the curves of the pulmonary artery. After ex- 
amining the valves, myocardium, aortic intima, etc., dissect out the 
coronary arteries with probe-pointed scissors. 

Lastly, unite the auricular and the ventricular incisions of each 
side by cutting through the auriculoventricular septa (Fig. 74). In 
Fig. 80 is shown how well the auricle and ventricle of the left side 
may be examined after the completion of this incision. The knife is 
best introduced from the auricle to the ventricle with the edge of the 
blade down and then turned, the cutting being done from within 
outward. It will be noticed that the instruments are passed through 
the valvular openings in the same direction as the blood flows. The 
valves will not be injured by this method and the entire heart can be 
folded together so as to show its original contour (Fig. 81). In 
extreme mitral stenosis it is often advisable not to complete the left 
auriculoventricular incision. 

A simple method of opening the heart, and one which yields fair 
results, is to place two fingers on the anterior ventricular septum, which 
is recognized by the situation of the anterior coronary artery, and make 
two parallel incisions into each ventricle. The pulmonary artery and 
the aorta may then be opened. 

The heart, freed from blood and clots, is now to be weighed. 

The gross appearance of the heart, as well as the thickness, color, 
and consistence of the various parts of the cardiac muscle, can now 
be observed. The wall of the right ventricle is normally from 2 to 3 
millimetres thick (in women slightly less than in men) and may 



io 6 POST-MORTEM EXAMINATIONS 

pathologically measure from 7 to 10 millimetres. The thickness of the 
wall of the left ventricle is from 7 to 10 millimetres, and may be in- 
creased to 25 milimetres or more by pathologic changes. The estima- 
tion o\ the weight of the heart is one of the means of determining 
whether or not a true hypertrophy is present. The normal heart 
v eighs about 250 grammes in women and about 300 grammes in men; 
but when hypertrophied it may weigh over a kilogramme. In the 
puerperal state the heart is normally increased in size, the right side 
often dilated (Letulle), the subpericardial fat increased, and hemor- 
rhages may occur. 

The color of the heart muscle varies according to the amount of 
blood it contains, but is always lighter and more grayish red than the 
skeletal muscles. It may be of a brownish red or even brown, as in 
anaemia and brown atrophy of the heart. In the latter condition the 
tortuous vessels and mucoid covering form a striking picture. The 
scattered yellowish patches seen throughout the muscle appear in bands, 
making a sort of net-work (wren's breast or tiger markings). This 
yellow streaking is often most conspicuous on the papillary muscles of 
the left ventricle. When this condition is at all extreme, the endo- 
cardium and pericardium will be found greatly thickened. 1 In septic 
conditions the heart is of a dirty-red color and very friable. Light- 
gray spots or streaks indicate the formation of fibrous tissue. The 
consistence of the heart muscle varies with the color: brown hearts 
are hard and dense, while those of a yellowish tinge are apt to be soft 
and flabby. The fibroid heart is always hypertrophied. After dilata- 
tion of an hypertrophied heart sets in, the muscle becomes softer by the 
process of fatty degeneration. The heart muscle is very soft in sepsis, 
and in cases of heart weakness developing after infectious diseases, 
especially after typhoid fever and diphtheria. 

Hypertrophy and dilatation are usually associated with each other. 
In concentric hypertrophy the walls are thickened and the cavities are 
-mailer than normal. As this condition is often due to post-mortem 
contraction or to marked systole, the heart should be soaked in tepid 
water before the measurements are taken. One may also distinguish 
simple hypertrophy, where overgrowth of the walls is found associated 
with normal cavities; eccentric hypertrophy, or hypertrophy with 
dilatation; and pure dilatation without hypertrophy. The highest 



1 E. Beer, Jour, of Path, and Bad., December, 1903. 



TECHXIC OF EXPOSING THE THORACIC CAVITY IO ; 

degrees of hypertrophy occur in cases of double aortic disease, where, 
too, moderator bands are sometimes found. The conical shape is often 
lost by the broadening- of the apex and deepening of the muscles. 

In the examination of the auricles an aperture in the foramen 
ovale may be overlooked if the heart is so held as to put the auricular 
wall too much on the stretch. As the communication between the 
auricles usually takes place by openings most frequently coming off 
from beneath the former edges of the valve, all suspicious cracks, ori- 
fices, or slit-like communications should be searched for with a pointed 
probe while the heart is relaxed, care being taken not to tear or puncture 
the tissue or to mistake the ending of the coronary veins, which empty 
near the obliterated opening, for a patulous foramen. In the left auri- 
cle the pulmonary veins rarely come out intact ; should they do so, a 
V-shaped incision is made between each pair so as to expose them. The 
" dog's ears" are opened by cutting towards their tips, with an extra 
incision transverse to this should it be required. Softening clots may 
then be discovered which otherwise would escape attention. 

If it be desired to follow out the subclavian vessels by careful dis- 
section, the entire clavicle of that side should first be removed. 

If a sound be used for finding the opening of the thoracic duct into 
the vein, care must be taken not to injure the valve which is present 
at this point. It is much more difficult to find the entrance of the 
lymphatic vein of the right side at the junction of the jugular and the 
right subclavian veins, as the parts are correspondingly smaller on 
this side of the body. 

The situation of the mitral and pulmonary valves can be easily re- 
membered by the mnemonic Martin Luther, The Reformer, — mitral 
on the /eft side, tricuspid on the right. That there is but one posterior 
cusp to the pulmonary valve and one anterior cusp to the aorta aff< >rds 
an easy way to recall this oft-forgotten point. 

Removal of the Lungs. — To remove the lung the left hand, palm 
inward, is introduced along the costal curve until the under portion of 
the upper lobe can be elevated without undue pressure being made 
upon the pulmonary tissue. Should there have been no antecedenl 
inflammation and consequent adhesions, a condition especially liable to 
be found at the apices, this procedure is readily accomplished, but 
sometimes, when the adhesions are very strong and cannot be broken 
down by the hand, a probe may be used for this purpose, or it may 
be necessary to dissect away the costal pleura and even the ribs and 



[0 g POST-MORTEM EXAMINATIONS 

remove them along with the lung. When this condition is found in 
the performance oi routine postmortems, the examination of the affected 
lung may be accomplished by making the incisions while the organ is 
still in the body. The upper lobe is now carried away from the median 
line of the body, anteriorly and downward, thus exposing the structures 
forming the root and giving a fine picture of the arch of the aorta. 
Then, separating the index and middle fingers of the left hand, the 
root of the lung is surrounded so that the upper lobe rests on the palm. 
In this way pressure can be made downward and away from the spinal 
column. Next a perpendicular incision should be made in the direction 
of the spinal column and the bronchus severed. The advantage of 
this procedure is that it enables the operator to observe the character 
of the fluid in the bronchus, avoiding its (otherwise very probable) 
contamination with blood. When the character of the fluid is noted, 
the rest of the structures, including the intercostals arising from the 
aorta, may be severed with a few horizontal incisions, care being taken 
to avoid cutting the aorta, the oesophagus, the large azygos vein, and 
the thoracic duct. It is well to remember when cutting these vessels 
that the left bronchus, which is considerably longer and smaller in 
diameter than the right, is situated below the left pulmonary artery, 
while the right undivided bronchus is entirely above the right pulmo- 
nary artery. The left lung should be removed first, and, as it has 
usually two lobes while the right has three (I have seen this condition 
reversed but twice), there is no necessity of adopting any method 
of distinguishing them after they have been removed from the body. 
Then, too, the left lung has a depression in its anterior border for the 
apex of the heart, it is longer and narrower than the right, not quite so 
heavy, and, as already stated, the arrangement of the bronchus and 
artery is different on the two sides. If, however, it is deemed necessary 
to do this, a single cut in the apex or bronchus of the left lung and 
two in the right will afford a ready means of distinguishing the one 
from the other. Normally, the lungs are darkened from inhalation of 
pigmented material, the deposit of pigment often assuming a mosaic 
or net-work appearance, corresponding to the situation of the lym- 
phatics in the external lobules of the lung. Examine the visceral pleura 
for fibrinous deposits, exudates, adhesions, etc. ; note the color, which 
varies with the age, the quantity of contained blood and air, minute 
hemorrhages, excessive pigmentation, cicatrices, spicules of bone, em- 
physematous spots, miliary tubercles, calcified tubercles with cheesy 



v^^ifr^yj^B 






1. 1 ?/ 


^B H' 


' ? - 




Ah*. 


™ ' ? /. 


*j[i^ 




v 



Fig. 82.— Method of opening the left lung. The organ, lying on its posterior surface, is held steady 

by slight pressure with the left hand on its upper portion, while a long, clean cut is made from the apex 
to the base of the lower lobe. In opening the right lung the incision is best made in the opposite direction, 
— />., from the base to the apex. 




Fig. S3. — Lung laid open for minute inspection. The lung from this case was emphysematous and 
showed bronchiectasis. Letulle makes seventeen incisions in the lung in its examination. 




: — Method of opening the branches of the pulmonary vein. The artery is tliiik<-i and more 
elastic than the vein. The veins are best opened after the primary incisions shown in Fig. 83 hav< 
made. It is naturally impossible in the same lung to make a complete dissei ti<>n <>' the bron< hi, artery, 
and veins, owing to cutting of vessels not belonging to the system and" tion. 




Fig. 85.— Method of opening the bronchi and their ramifications. 



TECHXIC OF EXPOSING THE THORACIC CAVITY IO o, 

interiors, nodules, patches of consolidation, hemorrhagic and anaemic 
infarcts, tumors, infectious granulomata, etc. The lungs should be 
weighed at this time, before they are opened for further study. 

Each lung is then carefully and lightly palpated from above down- 
ward throughout its entire extent by running the fingers over its sur- 
face, the fissures being separated and the anterior and posterior edges 
examined. By gentle pressure between the fingers crepitation is now 
produced. What this is like in the normal lung can be learned only by 
actual trial. In marked emphysema the crackling sound of the larger 
blebs as they break can sometimes be heard across the room. The 
presence of liquid naturally decreases crepitation. In hepatization the 
pulmonary parenchyma may break down even under gentle pressure. 
After squeezing a crepitant portion of the lung, there is ordinarily 
enough air left in the tissues to cause the pieces to float upon water. 
An interesting experiment in cases of atelectasis, infarcts, etc., portions 
for microscopic study having been previously removed, consists in 
blowing air forcibly through the bronchus by means of a cannula con- 
nected with a bellows. 

Placing the lungs upon their posterior surface on a board, rather 
than upon the more slippery stone table, the lower lobe of one lung is 
grasped with the thumb, the remaining fingers seizing the upper lobe ; 1 
in this way the organ may be firmly held (Fig. 82). With a single 
stroke an incision should be made from apex to base, commencing at 
the lateral convexity and passing to the entrance of the large vessels 
in the direction of the bronchi, the lung being now laid open like a 
book (Fig. 83). In the case of the left lung the base had better be 
turned towards the operator, while in the right it will be vice versa, 
requiring an extra incision to open the middle lobe. Immediately note 
the color of the cut surface. The normal color without blood is light 
gray, while with different quantities and qualities of blood the shade 
ranges from light red or brick-red to dark, black, or blue-red. Tn 
heart disease the color of the pulmonary tissue is apt to be brown ; in 
anthracosis it is black. The amount of hypostatic congestion, and the 
character of the fluid which exudes on lightly squeezing with the 
fingers areis not intended for microscopic study, arc now determined. 
A microscopic examination of the scrapings collected by passing the 

1 If the index-finger be introduced into the fissure between the lobes (and this 
method holds the lung very securely), care must be taken not to CUl the finger in 

±he subsequent procedures. 



IIO POST-MORTEM EXAMINATIONS 

knife-blade over the cut surface should be made. The appearance of 
the surface after removal of the liquid is determined, and any unusual 
spots more carefully examined. Next it is necessary to examine the 
substance of the lung for cavities, to observe the shape and position 
of areas of consolidation, and to ascertain the specific gravity of con- 
solidated areas in cold water. In pneumonic cases the entire lung may 
be placed in water to determine the portion containing air. A hemor- 
rhagic infarct or a portion of an apoplectic lung will sink in water, as 
well as the lung of croupous pneumonia. Cubes of normal lung may 
sink in fluids having a low specific gravity. 

Examination of the Pulmonary Vessels. — Now is the time 
to open the pulmonary veins (Fig. 84), artery, and bronchi (Fig. 85). 
Parallel or transverse incisions may be made, but care should be taken 
not to make them so deep as to detach any portions of the lung. The 
pulmonary arteries resemble the veins in character, though they are 
thicker, more elastic, and whiter than the latter. By following the 
pulmonary artery up on its anterior aspect from the heart there is no 
danger of mistaking one for the other, this error most often occurring 
when the dissection is not started until after the lungs have been 
removed from the body. Again, there is but one artery for each lung, 
while there are two veins. 

Removal in One Piece and Subsequent Examination of 
Tongue, CEsophagus, Trachea, and Adjacent Structures. — It 
is frequently advisable to excise as one piece the tongue, oesophagus, 
thyroid gland, trachea, epiglottis, etc., so that a minute examination 
of these parts may be made while they are exposed to good light in a 
convenient situation. For this purpose, in those cases where disfigure- 
ment of the body is of no importance, the primary incision over the 
thorax may be extended up to the symphysis mentis and the parts 
dissected out with ease. Orth's method of doing this is as follows: 
The skin is first reflected. Then by the use of the cartilage-knife an 
incision is made into the mouth at one angle of the jaws as close as 
possible to the bone, cutting with a sawing motion to the chin and then 
back on the other side to the angle of the jaw, severing the geniohyo- 
glossus muscle. The tongue, after being separated from the jaw, is 
pulled down with the forceps held in the left hand, after which the 
soft palate should be separated from the hard by the use of a knife, 
including in the operation the tonsils. A cut should now be made as 
high up as possible to remove the pharynx, trachea, and oesophagus 




-Method of r< 
without i 



moving tongue, tonsils, oesophagus, trachea, etc., in a Bingle piece, 

icising the skin more than is done in the primary cut. 



Palatine arch incised 
Tonsil 



iThyroid gland. 

Common carotid artery 
Left subclavian artery 

(Esophagus laid opei: 




Palatine arch incised 



Common carotid artery- 
Right subclavian artery 



Aorta 

Right bronchus 



Peribronchial lymph glands 



Fig. 87.— Examination of the organs of the neck. The arrows show the direction in which the incisions 
in the tongue and in the posterior wall of the oesophagus are to be made. (After Nauwerck.) 




:\ 



Fig. 88.— Method of opening trachea posteriorly. The incision starts from above and extends 

downward. 




Fig. 89. — Examination of trachea and vocal cords. The incision may be made anteriorly, thus 
leaving the walls between the two parts intrnt. 




the intestines preparatory to their removal. They are tied in two places, 
a foot or so above the ileocaecal valve. 




Fig. 92.— Bucket method of opening and cleansing intestines, especially useful in private cases. 



TECHXIC OF EXPOSING THE THORACIC CAVITY XII 

from the spinal column and the deep pharyngeal muscles. This should 
be done with small perpendicular incisions on the spinal column 
through the retropharyngeal and retro-cesophageal tissue, the tongue 
being pulled strongly forward. The parts may now be left intact for 
later dissection, or the oesophagus may be cut off just above its entrance 
into the stomach and the trachea below the vocal cords. These parts 
may be removed in a single piece, however, without the incision being 
extended to the chin, as by careful manipulation the hand can tear 
the skin away anteriorly from its attachments by working from 
beneath, and a knife may be introduced from below into the centre 
of the tongue (through the geniohyoglossus muscle) posterior to its 
fraenum, thus leaving the tip in situ in case an examination of the 
mouth is to be made. (Fig. 86.) By a circular incision of the muscles, 
fasciae, etc., with the knife beneath the skin, keeping as close as pos- 
sible to the bony walls of the jaw, to the carotids, and to the bodies 
of the vertebrae, the pharynx, larynx, trachea, and oesophagus may be 
separated, drawn forward and downward, and removed. The tonsils 
are either torn out bodily with the fingers from below, or else incised 
while in the body and examined from above or below by reflected 
light. The velum palati may also be removed by cutting the hard 
palate in front and dissecting it away from its bony attachment. This 
should always be done in cleft palate. The edges of the tongue may 
be examined for injuries, such as wounds made by the teeth during 
a fatal convulsion. The mucous membrane is flattened in syphilis, 
and the tongue may be the seat of lymphangioma. The vessels of 
the arm should now be cut and the arch of the aorta detached from 
the oesophagus and bronchi. The whole aorta may be examined later, 
if it is deemed better, or this vessel as far as the diaphragm can be 
removed with the oesophagus. This procedure is particularly useful 
when disease of the latter is suspected, as a cancer of the gullet may 
rupture into the aorta or an aneurism of the aorta break into the 
oesophagus. The aorta is from seven to eight centimetres in diameter 
at its commencement and gradually narrows to forty-five or even 
thirty-five millimetres in the abdominal cavity. The oesophagus and 
the trachea are preferably opened up posteriorly throughout their 
entire extent. (Figs. 87, 88, and 89.) Carefully examine the vocal 
cords; see if there are any tumors, syphilitic or tuberculous ulcera- 
tions, inflammation, malformations, foreign bodies, diphtheritic mem 
brane etc. The condition of the mucous membrane of the trachea and 



i i _> POST-MORTEM EXAMINATIONS 

the elasticity of its cartilages should be carefully tested. I have seen 
the whole transformed into a rigid tube by infiltration with lime salts. 
The trachea and larynx may show abrasions and injuries, as by cut 
throat, deformities, stenosis, pressure defects, etc. The oesophageal 
veins frequently carry on a large part of the collateral circulation in 
cirrhosis of the liver, and the rupture of one of them may cause death 
from hemorrhage, much blood being found in the intestinal tract. The 
oesophagus may show peptic or typhoid ulcers, and diverticula of 
various kinds and degrees are seen. Ulceration from cavities, as well 
as those just mentioned, may on healing result in stricture, which as 
time goes on may be the starting-point of cancer. 

In cases of strangulation, as by hanging or otherwise, the examina- 
tion of the vessels of the neck is of great importance. For this purpose 
the incision behind the ear, made for the removal of the brain, may 
be extended down the neck, and the skin, fat, and superficial fascia 
of the face dissected away, thus making easy the exposure of the 
jugulars, carotids, etc. The tearing of the intima of the carotid indi- 
cates hanging or strangulation; marks produced by pressure of the 
rope, in the form of parchment-like skin at the sides of the neck and 
hemorrhages into the tissues, are also found after death by hanging. 
Emboli of the carotid may cause sudden death, and thrombophlebitis 
of the jugular in cases of thrombosis of the lateral sinus is to be 
searched for. Aneurisms are sometimes seen. Hemorrhages into the 
sympathetic nerves may occur in cases of fever with delirium and of 
heat-stroke; pigmentation and fatty changes also take place in the 
cachexias and in fevers. 

The finding of the carotid body is facilitated by the removal of the 
common carotid artery along with about one-half inch of the internal 
and external carotids. The ganglion is located usually at the angle 
formed by the bifurcation of the carotid, but it may be situated at any 
place in this neighborhood. It closely resembles the superior cervical 
ganglion and has the size of a grain of rice, is somewhat oval in shape, 
vascular, and of good consistency. It is attached to the artery by 
means of a small band of connective tissue; bands from the capsule 
divide it into nearly equal parts and again into lobules. Funke 1 has 
tabulated fifteen tumors arising from the carotid body, his own case 
being a perithelioma. 

1 Amcr. Med., July 16, 1904. 



CHAPTER VIII 

DISEASES OF THE HEART, BLOOD, BLOOD-VESSELS, AND 
LYMPH-VESSELS 

Anomalies. — Abnormalities in the development of the heart are 
frequent and varied, occurring especially in non-viable infants. Thus, 
one may find acardia, double hearts, two- or three-chambered hearts, 
rudimentary hearts, malformed blood-vessels, premature closure or 
patency of fetal passages, as of the foramen ovale and ductus arteri- 
osus, imperfections of the septa, increase or decrease in the number 
of semilunar leaflets, stenosis and atresia of the pulmonary, aortic, and 
arteriosal conuses, transposition of the primary arterial trunks, ectopia, 
with deformity of the anterior part of the chest, etc. Dextrocardia 
may be part of a general congenital situs inversus or be confined to 
the thoracic organs alone. Acquired malformations are considered 
under the separate diseases of the heart. 

Blood. — Many of the changes which the blood undergoes are 
macroscopic and can be studied post mortem, though it should be 
remembered that numerous factors tend to alter its composition and 
color in a dead body. A pocket spectroscope and a Tallqvist or a 
Wetherill (Plate III) haemoglobin scale are useful for studying the 
characteristics of the blood. Reproductions of the spectra of haemo- 
globin, reduced haemoglobin, carbon-monoxid haemoglobin, etc., will 
be found in many of the works on physiology and toxicology. In 
using the Tallqvist's blood-color scale due allowance must be made 
for the difference in the color of the blood after death and for the 
abstraction of the water. At my request. Dr. Wetherill has kindly 
prepared a post-mortem color scale for showing the percentage of 
haemoglobin in the blood twenty- four hours after death. 1 

The method of using the scale, which for the sake of convenience 
has been placed upon the inner back cover (Plate III), is quite simple. 

1 The writer is at present engaged upon the preparation of a scale designed to 
show the changes of color in human blood twenty-four hours after death resulting 
from the more common poisons. He will be thankful to receive from the reader 
reproductions showing any such alterations except those induced by hydrocyanic acid 
and illuminating gas. 

8 "3 



[14 



POST-MORTEM EXAMINATIONS 



A drop of blood taken from one of the large veins, such as an in- 
nominate, "i- From the right side of the heart, is placed upon or 
absorbed by a small piece of filter-paper or white blotting-paper and 
held in the centre of the disk, so as to compare the color with the scale 
in daylight at an angle (by preference) of 45 °. As soon as the 
colors are nearly matched, the paper is run out along the black dividing 
line, thus affording an opportunity of forming an intermediary judg- 
ment, which can be approximately determined to within 2.5 per cent. 
The black lines separating the colors and the outer white paper best 
bring out by contrast the various shades of color. 

While printing this scale, the opportunity was afforded of supplying 
a copy of Dr. Wetherill's moisture scale, which is naturally of more 
use clinically than at the postmortem. The change in color depends 
upon the action of moisture on filter-paper soaked in a four-tenths of 
one per cent, of a saturated solution of the chlorid of cobalt. To 
measure the moisture in a room or upon the surface of a dead or 
living body, the disks are dried over a burning match or in a desiccator 
and placed under celluloid or glass to exclude the atmospheric con- 
ditions, if the latter procedures be desired. After ten minutes a com- 
parison is made with the scale and the percentage determined. In 
uraemia and diabetes the skin is dryer, as well as upon the side af- 
fected by a recent paralytic stroke. The scale may be used for de- 
termining the amount of moisture in the air at the place where the 
body is found or the autopsy performed. 

The specific gravity of the blood is best obtained with the specific- 
gravity bottle, there being no difficulty here, as during life, in securing 
the desired quantity of blood. Hammerschlag's method of mixing 
benzol and chloroform of a known specific gravity until a drop of 
blood remains stationary may also be employed. The specific gravity 
of the blood in health is normally from 1057 to 1059, and varies 
directly as the amount of the haemoglobin present. In leukaemia the 
specific gravity is high, while after drowning it differs according as 
the person has been drowned in salt or fresh water. The cryoscopic 
index is — ( >-S7° C., showing practically no variation during health. 1 
For its use in drowning, see Chapter XXVI. 



1 For a recent article on cryoscopy, see Cattell, International Clinics, April, 
1904. Revenstorf (Vjhrschr. f. gericht. Med., vol. xxii, 1903) determines by this 
method the length of time which has elapsed since death. 



BLOOD j x * 

There may be observed at the time of the postmortem all degrees 
of coagulation of the blood, from an almost absolutely fluid condition, 

as in poisoning by hydrocyanic acid, to a hard and dense fibrinous 
clot, — the so-called heart polyp, — which contains almost no red blood- 
corpuscles. The firm, yellowish "chicken-fat" clots, seen so fre- 
quently in pneumonia, adhere to the walls of the heart and indicate 
slow death, with gradual paralysis of the heart's action. When all the 
coagula are rich in fibrin, some acute inflammatory process has caused 
an increase in the leucocytes and blood-plaques, the generators of 
fibrin. In the left auricle they at times assume polypoid or spherical 
shapes, and may even become attached to its wall and undergo organi- 
zation. The ordinary post-mortem coagulum is the red clot, the so- 
called currant- jelly clot, which is not attached to the endocardium, 
though it may adhere to the muscular interstices of the heart. Hyperi- 
nosis, or increased capability for fibrin formation in the blood, is at 
times met with in certain anaemic affections and infectious diseases. 
Hypinosis, or decreased capability for fibrin formation, occurs in 
leukaemia, hydremia, certain of the acute exanthemata, hemorrhagic 
diathesis, obstruction of the biliary tract, and in cases of suffocation 
or intoxication with certain poisons, as carbonic acid. Methaemo- 
globin, found in cases of poisoning by chlorates, nitrites, toadstools^ 
etc., gives a brownish tinge to the blood. In putrefaction, if the blood 
be left standing, the clear serum separates and leaves a yellowish- 
green sediment. Under the microscope shadows of red cells are seen. 
The blood is normally alkaline, but at the end in Asiatic cholera it may 
be markedly acid or its alkalinity much diminished. 

The following diseases may be diagnosed by their agglutinative 
reaction : Typhoid fever, paratyphoid, dysentery, Malta fever, cholera. 
plague(?), tetanus (in the horse, but not in man), psittacosis, tuber- 
culosis ( ?) , and pneumonia. The reaction with the proteus may be 
used to distinguish between invasion after death and infection during 
life. Auto-agglutination of the erythrocytes has been observed in 
Hanot's hypertrophic cirrhosis. Flexner believes that the liability of 
the red corpuscles to become agglutinated in the blood-serum is the 
cause of thrombi which so frequently occur in certain of the infectious 
fevers, as typhoid. 

Pathologic Conditions. — (a) Plethora Vera. — A condition in 
which all the elements of the blood are proportionately increased, (b ) 
Plethora Serosa. — A marked increase in the watery constituents, ap 



u6 POST-MORTEM EXAMINATIONS 

pearing after transfusion, increased ingestion of liquid, acute cardiac 
failure, etc. (c) Olygemia. — A diminished amount of blood; occurs 
only as a temporary condition, (d) Hydremia. — Abnormal increase 
in the watery portion of the blood; seen in cardiac, pulmonary, 
hepatic, and renal diseases. In hydremic plethora there is an absolute 
increase of serum. If relative, it is called oligocythemia, (e) An- 
hydrcemia. — Here there is a concentration of the cellular elements of 
the blood clue to an abstraction of its watery constituents, the blood 
becoming thick and even tarry, as in cholera. It is seen at times after 
tapping, as for ascites, and in starvation, (f) Hemolysis. — Destruc- 
tion of red corpuscles ; occurs after burns, certain poisons, infectious 
fevers, etc. (g) Lymphocytosis. — An absolute and relative increase 
of lymphocytes; commonly associated with hereditary syphilis, scurvy, 
chlorosis, pernicious anaemia, Graves's disease, splenic tumors, per- 
tussis, pneumonia, and lymphatic leukaemia, (h) Eosinophilia. — An 
increase in the number of eosinophiles ; occurs in asthma, fibrinous 
bronchitis, acute and chronic skin diseases, especially in trichinosis, 
ankylostomiasis, also after acute infections and with malignant tumors 
(moderate increase). It is a compensatory reaction with diseases of 
the spleen. Eosinophiles are decreased after castration, and in the 
febrile stages of pneumonia, grippe, typhoid, diphtheria, and sepsis. 
(i) Myelocytosis. — An increase in the number of myelocytes is always 
pathologic, and is seen in greatest degree in myelogenous leukaemia, 
pernicious anaemia, acute infections, as typhoid, mania, Basedow's 
disease, syphilis, tuberculosis, osteomalacia, etc. It may occur in all 
diseases with marked anaemia. (/) Polycythemia rubra is an absolute 
increase in the red cells; seen in cured cases of anaemia, — usually 
associated with engorged organs, — in new-born children, and in per- 
sons living at high altitudes or suffering from chronic phosphorus and 
carbon monoxide poisoning, (k) Anemia. — A diminution in one 
or more of the constituents of the blood. (/) Primary, Essential, or 
Idiopathic Anemia. — An anaemia, the cause not definitely known, 
usually attributed to the blood-making organs, and characterized by a 
disproportionate reduction in the elements of the blood, (m) Second- 
ary, Simple, or Symptomatic Anemia. — An anaemia due to a definite 
cause, as an Anchylostomum duodenale, Anguillula stercoralis, Bothri- 
ocephalus latus, Ascaris lumbricoides, Tricocephalus dispar, trichinosis, 
infectious fevers, etc., and characterized by a proportionate reduction 
in the dements of the blood ; shown by changes in the specific gravity, 



BLOOD II7 

color, size, and shape of red cells, etc. (n) Poikilocytosis. — Altera- 
tion in the shape of red corpuscles (crenated, reniform, and pyriform 
are most common), (o) Macrocytosis and Microcytosis. — The red 
cells are respectively increased and diminished in size, (p) Leucocy- 
tosis. — Increase in the number of white blood-cells without alteration 
of the relative numbers of each variety ; marked in the new-born, in 
pregnant and parturient women ; usual at postmortem ; appears with 
many infections, suppuration, malignant disease, and hemorrhage. 
(q) Lcucopcnia. — A diminution in number of white blood-cells; seen 
most characteristically in typhoid fever, starvation, cancer, grippe, 
measles, tuberculosis, typhoid fever, Hodgkin's disease, and phthisis; 
normal in pregnancy, obesity, alcoholism, nephritis, icterus, typhus, 
malaria, and cardiac and pancreatic diseases, (r) Lipcemia. — Fat in 
the blood, giving it a milk}- appearance ; seen in leukaemia, diabetes, 
alcoholism, phthisis, etc. (s) Uremia. — The presence in the blood 
of an excess of chemical compounds, as urea, which should be elimi- 
nated by the kidneys or other excretory organs. There may have 
been during life an increase in blood-plaques, but they are most difficult 
of demonstration even shortly after death. In uraemia, besides the 
macroscopic lesions of oedema of the brain, a condition of chromatolysis 
of the cells in the central nervous system may be demonstrated. The 
destructive changes are especially found in the motor cells, and may 
be followed later on by degeneration of the motor tracts. 1 

Blood-Stains. — When any suspicion of violence occurs, look care- 
fully for blood-stains. If in doubt, treat all suspicious findings as if 
they were such, unless some special reason exists for not doing so. 
Such stains should be most critically examined in the privacy of the 
laboratory before expressing an opinion as to whether or not they are 
consistent with human blood. Try to ascertain : ( I ) Their connec- 
tion with the body under examination or with the person suspected 
of the crime. (2) Their extent, using great care in determining the 
nature of the substance stained. (3) Conditions, — whether fluid or 
clotted, wet or dry, cracked or caked, etc. (4) How made, — whether 
by smear, by splash, by flow, by soaking up, as in cloths, etc. (5) Con- 
nect, if possible, the amount, shape, and condition of the stains with 
their probable source, and note any peculiarities. When practicable, 
preserve parts or all of stains. It is often well to saw off an entire 

'Editorial, Jr. Amer. Med. Assoc, April 23, 1904. 



Il8 POST-MORTEM EXAMINATIONS 

step or remove a panel of a door in order to produce the same as evi- 
dence in court. In the present state of our knowledge it is not prac- 
ticable to state from what part of the body the blood came and the 
age of the stain, though the more recent the blood the more soluble 
it is. 

Two illustrations from my case-book will show the importance 
of this line of research. A man committed rape on a seven-year-old 
child and murdered her. Blood was seen on the fly of his trousers 
by his room-mate. In order to divert suspicion from himself, the 
murderer accused his room-mate of the crime. The trousers of both 
men were sent to me for examination. In the pair of pants belonging 
to the perpetrator of the crime the lining of the fly had been cut away 
and neatly sewed, but there remained a few telltale threads containing 
blood, which was found to possess the characteristics of human blood. 
On the trousers of the other man was found a red substance, which 
examination showed to be lumberman's red chalk, the crime having 
been perpetrated in the backwoods. In the second case blood splashes 
on a white curtain were stated by a murderer to be red paint which 
one of his children had put there with a paint-brush. 

The presence or absence of blood is determined by ( i ) the physi- 
cal examination; (2) chemical tests; (3) spectroscopic examination; 
(4) microscopic examination, and (5) the hemolytic serum test. 

The agglutinative reaction or antiserum test for the diagnosis 
of human blood has been applied in a number of recent trials. It 
would seem to afford positive proof of the special source of the blood 
under examination, though Robin secured the reaction from the blood 
of a monkey and Linossier, Nuttall, Dieudonne, and others have demon- 
strated the reaction in pus, nasal mucus, saliva, urine, pleural exudate, 
and sweat derived from the human body. Uhlenhuth 1 was put to a 
severe test by the German Department of Justice. Various objects 
stained with the blood of man and of different animals were sent to 
him, the nature of the blood being known to the Department of Justice 
but not to him. When the blood was furnished in sufficient quantities, 
his results in each case were positive. 2 One method of preparing the 

! Deutsche med. Wchnschr., September 11 and 18, 1902. 

' For an account of trial cases see Patek and Bennett, Amer. Med., Septem- 
ber 6, 1902, p. 374; Whittier, Amer. Med., January 18, 1902; Ferrar, Bolletino 
dclla reale Accad. medica di Genova, 1901, no. 7; Ogier and Stickis, Soc. de 
med. legale, Paris, May, 1901 ; and Bechtel case tried at Allentown, Pa., in 1904. 



BLOOD „ 9 

antiserum and applying the test is as follows : Ten cubic centimetres 
of defibrinated human blood, as that freshly obtained from the human 
placenta, are injected into the peritoneal cavity of a rabbit at intervals 
of six days, and after five such injections an effective serum should 
be obtained. Butza 1 prepares the animal by injecting- from ten to 
twenty cubic centimetres of a centrifugated human pleural exudate 
intraperitoneal^ into a rabbit for five or six successive days. The 
animal need not be killed, but bled again and again, as in the prepara- 
tion of the diphtheritic antitoxin. The blood should not be brought 
to too high a point of efficiency, as it will then require too high a 
dilution for practical purposes. The blood to be tested is diluted with 
water, one to one hundred, and filtered. Of this clear, slightly red 
solution two cubic centimetres are placed in a small tube and mixed 
with an equal quantity of 1.6 per cent, salt solution; six to eight 
drops of the serum of the rabbit are then added to each tube to be 
tested, but all will remain perfectly clear except the tube containing 
human blood. The reaction is extremely delicate and can be obtained 
with very slight traces even of old dried blood. The clouding should 
occur within thirty minutes in the proportion of 1 to 30, and a pre- 
cipitate within two hours ; other samples of blood remain clear after 
six hours. The test should always be repeated. Bordet, 2 Deutsch, 3 
Wassermann and Schiitze, 4 and Dieudonne 3 describe practically the 
same method as Uhlenhuth, and have obtained similar results. Bor- 
det and Deutsch each claim to have been the first to use this method. 

Corin 6 believes that the active principle of the serum in the bio- 
logic differential diagnosis of the blood is paraglobulin, for not only 
may blood-serum be used for the purpose, but also transudates con- 
taining globulin. The paraglobulin in an ascitic fluid was precipitated 
by magnesium sulphate, dried, and injected into animals in an aqueous 
solution. In like manner the paraglobulin can be precipitated from 
the blood of the animal experimented upon and preserved in pulver- 
ized form. This powder when wanted for use is dissolved in water 
and employed in testing the blood under examination. Biondi T finds 

1 Spitalul, 1902, vol. xxiii. p. 377. 

2 Annates de I'Institut Pasteur, 1899, pp. 225 and 273. 
Orvosik Lapja, 1901, no. 11. 

4 Bcrl. klin. Wchnschr., 1901. vol. xxxviii. no. 7. p. 187. 

'Munch, med. Wchnschr., 1901, vol. xlviii, no. 14. 

1 Vrtljschr. f. gerichtl. Med., 1902, vol. xxiii. p. 61. 

7 Vrtljschr. f. gerichtl. Med.. Suppl-Heft, 1902, vol. xxiii. p. 1. 



I2 o POST-MORTEM EXAMINATIONS 

that the reaction occurs with the semen, so that human and animal 
spermatic fluid can be differentiated. Meyer * has even shown that 
Egyptian mummies give this reaction. This test might, for example, 
have been used in the boiled and alkali-eaten bones found in the vat 
in the Luetgert case of Chicago. Evans and Gehrmann 2 have sug- 
gested this test for the purpose of distinguishing horse meat when 
used in sausages. The writer, in the International Medical Magazine, 
March, 1897, and earlier to his classes at the University of Pennsyl- 
vania, suggested the possibility of the Widal test being used in certain 
cases for the distinguishing of human blood. It may be noted that the 
paratyphoid reaction might in certain cases assist in diagnosing animal 
blood. 3 Leblanc 4 has endeavored to diagnose human blood by the 
form of crystallization assumed by the haemoglobin, but this method 
requires a considerable amount of blood. 

Abnormal Constituents of the Blood. — (a) Tumor cells, as in 
neoplasms growing into veins, portions of the valves of the heart 
and of thrombi, fat, as after a fracture, etc. (b) Blackish pigment 
particles, melanaemia, as in malaria, melanosarcoma, and Addison's 
disease, coal dust, often found in the spleen, etc. (c) Haematoidin 
crystals, (d) Bilirubin crystals in the shape of needles are sometimes 
found microscopically in a clot that has been well washed in water. 
They occur in icterus neonatorum, pernicious anaemia, acute yel- 
low atrophy, pyaemia, etc., but not in ordinary icterus, (e) Bile. 
Gmelin's test for bile may be applied direct to the serum of the blood, 
the bile sometimes imparting to the serum an orange-red tint which 
may be recognized by the naked eye. (f) Glycogen. The glycogenic 
reaction in the blood, first described by Gabritschewski in 1891, is 
determined by placing for one minute a blood smear, face down, upon 
a solution of iodin, iodid of potassium, and gum arabic. If the glyco- 
genic reaction is positive, small or large brownish granules are ob- 
served under the high powers of the microscope in the polynuclear 
leucocytes, or the cells themselves may even assume a diffuse brownish 

1 Munch, med. Wchnschr., April 12, 1904, p. 663. 

2 Amer. Med., vol. iii, p. 1062. 

3 The Marx-Ehrenrooth test will be found in Munch, med. Wchnschr., 1904, 
vol. li, no. 16. Deutsch's book is entitled Impfstoffe und Sera, Leipzig, 1903. 
Nuttall's article (Jr. of Hygiene, 1901, vol. i, no. 3) is the best of the early publi- 
cations in English. 

4 These, Paris, 1903. 



BLOOD I2I 

color. Some brownish extracellular masses may also be found. The 
reaction is found in suppuration, bacterial infection, uraemia, diabetic 
coma, etc. Locke and Gulland 1 have demonstrated that the reaction 
is always present in an acute attack of appendicitis, and may even 
afford valuable information concerning the severity of the disease. 
Serous pleuritis and simple obstruction of the bowel do not give the 
reaction, (g) Gas bubbles may be clue to putrefaction, as air-pro- 
ducing bacteria develop very rapidly after death. In fresh blood air 
bubbles, particularly when in the right heart and surrounded by a clot, 
are due to the entrance of air into the veins during life, (h) Charcot- 
Leyden crystals, seen in leukaemia. (i) Lower organisms, as the 
Spiroclicctcc of relapsing fever (not always found after death), the 
organisms of anthrax, influenza, tetanus, tuberculosis, typhoid fever, 
paratyphoid, Malta fever, glanders, etc., and micro-, strepto-, staphylo-, 
and diplococci, such as the Gonococci and Pncumococci, Plasmodia, 
Filaria sanguinis Jwminis, Distoma, found especially in the portal and 
splenic veins, Trypanosoma, and many other parasites. Many names 
have been given to those conditions produced by organisms and their 
products acting upon the living tissues of the body : as, septicaemia, 
where there are pyogenic micro-organisms in the blood and tissues, 
without areas of suppuration ; pyaemia, where metastatic or pyaemic 
abscesses are found in the tissues and organs of the body ; and saprae- 
mia, where the symptom-complex is produced by the presence in the 
blood and tissues of the vital chemical products known as toxins. 
These toxins may be formed by the action of pyogenic or saprophytic 
micro-organisms. { j) Various vegetable and mineral poisons, such 
as carbon monoxid, hydrocyanic acid, nitrobenzol, etc. 

Blood-Diseases. — Anccmia, Progressive Pernicious. — An idio- 
pathic, chronic anaemia characterized by definite blood-changes, by 
pallor of the mucous membranes, by a lemon-yellow coloration of 
the skin, and by progressively developing weakness without corre- 
sponding emaciation. It is most common in adults of the male sex, 
but may occur in children. Rare cases are seen during pregnancy 
and parturition. It is associated with an extreme anaemia, poor teeth, 
unclean mouth, overwork, and intestinal parasites, especially the Both- 
riocephalus latus and Anchylostoma duodenale. The chief changes 
seen in the blood during life, but which cannot always be demonstrated 



1 Brit. Med. Jr., April 16, 1904, p. 880. 



[22 POST-MORTEM EXAMINATIONS 

post mortem, arc: (i) Marked reduction in the number of red cor- 
puscles ( to one million or less per cubic millimetre). (2) Alteration in 
their shape, — poikilocytosis. (3) Alteration in size, — microcytes, 
macrocytes, megalocytes. (4) Nucleated reds, — normoblasts, megalo- 
blasts. (5) Increase of neutrophilic whites. (6) Haemoglobin markedly 
decreased, but color-index usually high and blood of a raspberry-red 
color. (7) Blood-plates absent or scanty. At the post-mortem the 
skin is, as a rule, lemon-yellow in color. The skin and the serous 
membranes commonly reveal hemorrhages, which may, however, be 
present only in the retina. Certain brown discolorations are often 
found, especially on the abdomen and buttocks. The subcutaneous 
fat is well preserved and of a light-yellow color. The muscles resem- 
ble horse-flesh and are often degenerated. The heart is usually large, 
flabby, empty, intensely fatty, and tawny-brown in color. The other 
organs exhibit fatty changes. The stomach may be normal or the 
disease may be associated with chronic gastritis, gastric carcinoma, 
or atrophy of the gastric tubules. Iron is deposited in excess in the 
lobules of the liver, especially in the outer and middle zones. The 
spleen and haemolymph glands show a marked leucocytosis and excess 
of iron pigment. The spinal cord may show extensive posterior scle- 
rosis with hemorrhagic foci, due to the action of the toxins and nerve- 
fibre degeneration. The lesions are usually most marked in the part 
of the tract farthest from the trophic centre. Changes in the ganglion- 
cells of the sympathetic system have been reported. The marrow of 
the long bones is reddish, resembling that seen in the infant. In per- 
nicious anaemia there is incomplete formation of serum. It is stated 
that the clot of pernicious anaemia and that of anaemia secondary to 
cancer may be distinguished by the contraction of the cancer clot and 
the resulting squeezing out of the serum. 

Chlorosis. — Chlorosis is a primary anaemia which occurs usually in 
girls between fifteen and twenty years of age, and is characterized by 
a marked diminution in the percentage of haemoglobin, by alterations 
in the number, shape, and size of the red blood-corpuscles in severe 
cases, and sometimes by hypoplasia of the circulatory and generative 
organs. The white blood-cells rarely show much variation. Cases 
of simple chlorosis rarely come to autopsy. Subcutaneous fat is 
usually well preserved or even increased in amount. The skin is pale 
and of a greenish hue, and other evidences of anaemia may appear. 
Areas of pigmentation, particularly about the joints, occasionally 



BLOOD I23 

occur. The internal organs will be found pale and flabby. The heart. 
large blood-vessels, and generative organs may show insufficient devel- 
opment. (Virchow.) The heart and large veins are often filled with 
a greenish clot. Thrombi, at times multiple, are common, especially 
in the femoral vein and the longitudinal sinus. Pulmonary embolism 
has been observed. 

Leucocythcemia {or Leukemia). — A primary anaemia character- 
ized by a great increase in the number of the white corpuscles, by an 
alteration^ in the relative proportions of the various white corpuscles 
the one to the other, and by marked structural changes in the lymphatic 
glands, spleen, and bone marrow. It may be (a) splenic, (b) medul- 
lary, (c) lymphatic, or (d) mixed. As a rule, the body is apparently 
well preserved, but in some cases emaciation may be extreme, while 
in others the amount of adipose tissue may be increased and of a 
peculiar punctate appearance, owing to the presence of petechial hem- 
orrhages. The skin is waxy and has a peculiar lemon-yellow color. 
The mucous membranes are blanched and cedema is often present. 
The blood is pale, even grayish, in color, the haemoglobin being often 
reduced one-half or more. It rarely clots with any degree of rapidity, 
and in the clot red cells settle, leaving a white film above. At the 
postmortem the heart and large veins may be found distended with 
large, greenish, pus-like blood clots. In splenic anaemia microscopic 
examination of the blood shows that the increased white corpuscles 
are largely myelocytes, while in the medullary form they are lympho- 
cytes. The white corpuscles are enormously and permanently in- 
creased, so that one white to twenty red, or even one to one. is not 
uncommonly found. The organs in general are pale ; the heart is 
flabby and frequently fatty in appearance. The liver, spleen, and 
lymphatic glands are usually markedly hypertrophied, while the thy- 
roid may be normal or but slightly enlarged. The thymus gland has in 
several instances been found enlarged. Lymphoid masses are seen in 
the lungs. The Peyer's patches are often increased in size. 

(a) In splenic anaemia, which is a comparatively rare form of 
the disease, the spleen is markedly enlarged, somewhat firm in con 
sistency. and of a reddish-brown color. The capsule is thickened and 
the whole organ is bound down by adhesions. The Malpighian bodies 
are frequently obliterated, their place often being taken by grayish 
white, circumscribed tumors throughout the organ. The hyperemia 
in some cases is so excessive that rupture of the spleen is said in occur 



124 



POST-MORTEM EXAMINATIONS 



from this cause. The vessels at the hilum are enlarged. Dropsy from 
pressure on the abdominal viscera may result. As in other forms of 
leukaemia, the bone-marrow may show decided changes, especially in 
the long bones. Instead of fatty tissue there may be splenization, or 
the marrow may resemble the consistency of the matter which forms 
the core of an abscess. (&) Medullary leukaemia very seldom occurs 
as an inflammatory process. Where the marrow changes are excessive, 
the flat bones — as, e.g., the sternum — undergo alterations similar to 
those occurring in the long bones. There is a hyperplasia of the 
red marrow; this may resemble pus or be of a dark-brown color. 
There may be localized swelling of the bone, (c) In lymphatic leu- 
kaemia the lymphatic glands throughout the body, especially those of 
the neck, the axillary and inguinal regions, also the glands of the 
mesentery and the intestines, are swollen, pale in color, firm to the 
touch, but seldom suppurate or show any tendency to run together. 
The spleen, liver, and lymphatic glands, as the tonsils, lymph-follicles 
of the tongue, pharynx, and mouth, often show marked thickening 
of their capsules. On section the glands are somewhat resistant, and 
often exhibit nodule-like bodies, which are firm in consistence and 
largely composed of proliferating leucocytes and connective tissue. The 
liver as well as the spleen is enlarged and may exhibit marked struc- 
tural changes. This form may be associated with, or most difficult 
to differentiate from, lympho-sarcoma. 

Von Jaksch's Ancemia. — This is a primary anaemia of infancy, 
closely resembling leukaemia, but without the visceral lesions. The 
red cells are diminished, though many of these are nucleated. The 
spleen, liver, and lymph-nodes are enlarged, and the number of leuco- 
cytes is increased. 

Osier's Disease {Chronic Cyanosis). — A chronic disease of people 
usually past middle life and not associated with dyspnoea, kidney, lung, 
or heart disease, but characterized by marked blueness of the skin. 
There is a marked polycythemia, the red cells varying from 10,000,000 
to 12,000,000 per cubic millimetre and the haemoglobin being increased 
as much as fifty per cent, above the normal. At the postmortem the 
heart and spleen are found enlarged and the internal organs markedly 
congested. At times small hemorrhages are noted. 

Hodgkin's Disease (Pseudoleukemia; General Lymphadenoma) . 
— A disease characterized by a progressive hyperplasia of the lymph- 
glands, by anaemia, and sometimes by secondary lymphoid growths in 



BLOOD io . 

the liver, spleen, and other organs, but with no severe leucocytosis. 
The lymphatic glands most frequently enlarged are those in the cer- 
vical, axillary, and inguinal regions, though the mediastinal, thoracic, 
and abdominal glands, especially the retroperitoneal, are often affected. 
In the early stages the glands are moderately enlarged, soft and elastic, 
isolated, and freely movable. Later they increase in size and tend to 
run together, become stony hard, and are surrounded by a dense cap- 
sule. The capsule may perforate, and the growth invade the surround- 
ing structures. On section the tumor appears grayish-white; it is 
smooth and the interior may be firm and dry or soft and juicy. Sup- 
puration sometimes occurs when the growth reaches the skin. Ema- 
ciation at the time of death may be extreme. The spleen and liver 
are usually somewhat enlarged, but rarely greatly so, and on section 
show lymphoid tumors varying in size from that of a pea to a walnut. 
The Peyer's patches frequently show enlargement. Pleural effusions 
are not uncommon. The skin may be the seat of adenoid growths. 
The glandular enlargements may be due to simple inflammatory hyper- 
plasia, lymphadenoma. or lymphosarcoma. The bone-marrow may 
be converted into a rich lymphoid tissue. The blood-changes are those 
of a distinct anaemia of the simple type. The red cells are less numer- 
ous and are slightly smaller: the haemoglobin is always diminished: 
the leucocytes are normal or decreased in number. 

Hcrmophilia. — An hereditary constitutional disease characterized 
by a marked tendency to excessive hemorrhage from very slight causes. 
It is transmitted through the females of a family to the males. Little 
regarding its morbid anatomy is definitely known, and therefore any 
opportunity for the study of a case post mortem should be taken ad- 
vantage of. The vessel-walls are unusually thin, brittle, narrow in 
calibre, and do not readily contract. In some cases the blood itself 
presents marked alterations. Owing to the ease with which the joints 
are injured, hemorrhages are often found about the capsules of joints, 
with inflammation of the synovial membranes. In a few cases in- 
crease in the number of red cells and diminution of white cells and 
blood-plates have been noted. Geier l finds the cytoglobin, which is 
produced by the destruction of the red blood-cells, to be markedly in- 
creased in haemophilia. 

Purpura. — This is characterized by extravasations of blond into 



1 Med. Obozrainic. Mosk.. 1904, vol. Ixi. no. 1. 



126 POST-MORTEM EXAMINATIONS 

and from the skin, by great debility, evidences of anaemia, and often 
multiple arthritis. Infections purpura is seen in pyaemia, septicaemia, 
malignant endocarditis, typhus fever, etc. The forms are (a) pur- 
pura simplex, (b) purpura haemorrhagica, (c) purpura rheumatica, 
(d) iodic purpura, (e) Henoch's purpura, (/) neurotic purpura, (g) 
mechanical purpura, (h) toxic purpura (seen in snake poisoning, after 
the use of certain medicines, etc.), (i) cachectic purpura. The blood 
clots slowly and imperfectly ; leucocytosis may or may not be present ; 
the blood-plates may be scanty; and the red cells are often reduced 
in number. There is a large percentage of lymphocytes and an in- 
crease in the eosinophiles. The skin is dry and pale, except for the 
blotches of extravasated blood, which vary from one to four milli- 
metres in diameter, are bright red in color, later become dark, and 
finally remain as brown stains. The hollow viscera and serous cavities 
may contain considerable quantities of blood-stained serum. The 
serous membranes and solid organs may also reveal hemorrhages vary- 
ing in size from a pin's head to the palm of the hand. Congestion and 
cedema of the lungs are frequently present. There is generally an 
acute diffuse nephritis. Ulcerations of the intestines with enlarge- 
ment of the solitary and agminated glands are sometimes found. In 
one of my cases, in which the purpuric blotches were unusually large 
and widely distributed over the body, a husband was accused of beating 
his wife and thus causing her death. 

Scurvy. — Scurvy is a constitutional disorder characterized by anae- 
mia, great debility, spongy gums, and tendency to hemorrhage. This 
disease is by no means so frequent as formerly, owing to better hy- 
gienic conditions and to the proper feeding of those in ships, prisons, 
work-houses, etc. The blood is dark and fluid; there is a decrease 
in the number of the red cells, many of which are pale and distorted ; 
microcytes are present; there is no leucocytosis. After death decom- 
position sets in rapidly. There is very little wasting of the subcu- 
taneous fat or of the muscles. The hemorrhagic patches observed in 
the skin during life are often obscured by post-mortem lividity ; oedema 
is common. The subcutaneous tissues, especially those of the lower 
extremities, contain a blood-stained fluid, with here and there dis- 
colored patches, some black and others of a pale color. About the 
back of the thigh and knee the muscles and tendons may be embedded 
in a thick, firm clot, and themselves contain numerous hemorrhagic 
foci. Occasional hemorrhages occur within the joints, or into any of 



BLOOD ,_,- 

the serous and mucous membranes or internal organs, especially the 
kidney and bladder. The gums are swollen and may present fungous 
appearances; they are sometimes ulcerated, and the teeth may have 
fallen out. Rarely there may be ulcers in the intestines. Hemorrhagic 
infarcts are at times seen in the lungs and spleen, the latter organ being 
enlarged and soft, while fatty changes are quite constant in the liver, 
kidneys, and heart. 

Scurvy, Infantile {Barlow's Disease). — Usually associated with 
improper food, such as too much malted or condensed milk. Cases, 
however, have been reported in breast-fed children. The most im- 
portant lesions are increased vascularity and extravasation of blood 
between the periosteum and the bone and into the cavity of the long- 
bones, especially those of the lower limbs, producing tumor-like swell- 
ings. Epiphyseal fractures are not uncommon. In fact, in the major- 
ity of cases there are bone changes analogous to those of rickets, and 
the disease often develops in a rickety child. 1 Deep-seated extravasa- 
tions may give rise to muscular swellings and in some cases to extrava- 
sations in the joints. Smaller extravasations are observed in the 
pleura, lungs, spleen, intestines, and kidneys. The gums are spongy, 
sodden, distended with serum, and sometimes covered with blood. One 
of the most characteristic lesions is extravasation of blood into the 
orbital cavity, causing displacement of the eyeball downward and for- 
ward. 

Diabetes Insipidus. — A constitutional condition characterized by 
continued secretion of large amounts of pale urine, of low specific, 
gravity, containing neither albumin nor sugar, attended with excessive 
thirst and at times with emaciation; usually the patient looks well 
nourished. It occurs most often in young males and is usually heredi- 
tary. The urinary system may show merely signs of the passage of 
an abnormal amount of liquid, — enlarged and congested kidneys, di- 
lated pelves, dilated ureters, and an hypertrophied bladder. 

Gout. — A constitutional disease characterized by excessive forma- 
tion of uric acid and the gradual deposition of its salts, especially 
sodium urate, in and around the joints of the extremities, producing 
an acute arthritis. Anatomical changes are found mosl frequently in 
the great toe, though the disease shows a marked tendency to involve 
the smaller joints, both of the feet and the hands. In acute St 
there are notable hyperemia and round-celled infiltration and diffusion 

1 Lancet, May 3. K>02, p. [246. 



I2 8 POST-MORTEM EXAMINATIONS 

into the joint and swelling of the ligaments. Macroscopically the 
joint is swollen, glazed, tense to the touch, and of a purplish color. 
In the chronic form the ligaments and fibrocartilages of the joint 
become infiltrated with chalky deposits (tophi). These consist of 
sodium urate^ in the form of crystalline needles or rhombs, which are 
quickly dissolved by hydrochloric acid, but whetstone-shaped crystals 
of uric acid make their appearance. Necrosis in the cartilage always 
precedes the formation of tophi (Ebstein). These deposits may be 
slight or may lead to enormous distortion of the joint. In somes cases 
the skin may ulcerate and the tophi be extruded. The deposits may 
be found in the cartilages of the ear, the nose, the eyelids, and occa- 
sionally the larynx. In some cases the synovial fluid contains crystals. 
In chronic cases the joint becomes immovable, due to the exostosis 
and excess of deposits. The kidneys usually show chronic interstitial 
inflammation, with deposits of urates in the form of small flakes or 
stripes, chiefly in the pyramids. Arteriosclerosis, with hypertrophy 
of the left ventricle, is very common. Cutaneous affections, such as 
eczema, are not infrequent. The blood contains an excess of uric acid. 

Varieties of Hemorrhage. — The following terms are applied to 
hemorrhages from various parts of the body : Epistaxis, hemorrhage 
from the nose ; haemoptysis, pulmonary hemorrhage ; hsematemesis, or 
gastrorrhagia, hemorrhage from the stomach; enterorrhagia, hemor- 
rhage from the intestine ; metrorrhagia, uterine hemorrhage not occur- 
ring during the regular menses; menorrhagia, excessive menstrual 
flow; post-partum, hemorrhage from uterus after delivery; comple- 
mentary, hemorrhage ocurring in some place other than that in which 
the original bleeding occurred ; consecutive or secondary hemorrhage ; 
extrameningeal, a hemorrhage external to the cerebrospinal meninges ; 
hemorrhage per diapedesis ; hemorrhage per rhexin. 

Hemorrhages, Causes of. — (a) Traumatism, (b) Acute inflam- 
mation, (c) Passive congestion, (d) Corrosive poisons, (e) Malig- 
nant growths. (/) Diseases of the vessels. (g) Rupture of an 
aneurism, (h) Cachetic disease, (i) Dyscrasias. (/) Nervous dis- 
turbances, (k) Vicarious menstruation. (/) Toxins. 

Many coroners' physicians give hemorrhage from the umbilical 
cord as a cause of death in new-born children. Although this fatality 
does occur, it is extremely rare, some obstetricians treating without 
tying the cord hundreds of cases without hemorrhage ; nor is the con- 
dition seen in the lower animals. It is facilitated by cutting the cord 



DISEASES OF THE HEART 12 g 

too close to the abdomen, by forced artificial respiration, and by the 
presence of haemophilia. It may come on several days after birth, and 
at the postmortem the liver appear especially blanched. 

Axgixa Pectoris. — A symptomatic affection commonly associated 
with more or less myocardial degeneration and occlusion of the coro- 
nary arteries from atheroma and thrombosis. At the autopsy the heart 
is often enlarged and the pulmonary artery and the cavities of the 
heart are filled with post-mortem clots. While aortic and mitral thick- 
enings are usually present, I have examined cases where they were 
absent. The coronary arteries are " pipe-stem" in character, the an- 
terior one being usually most markedly affected. 

Infiltrations axd Degenerations. — In fatty infiltration, or 
obesitas cordis, there is an increase of fat in those places where it is 
normally deposited, especially along the grooves of the larger blood- 
vessels. The deposits start from the outside and extend inward along 
the trabecular of connective tissue, while in fatty degeneration the 
changes originate from within. The heart may be embedded within 
such an enormous deposit of fat as to leave no muscle exposed to view. 
Fatty infiltration and degeneration occur most markedly in cases of 
poisoning, as by phosphorus, and the atrophy of the muscle may be 
very extensive. In such cases the heart is so soft that the finger can 
readily be pushed through its walls. Hyaline and amyloid degener- 
ation may also occur, as well as calcareous infiltration, fragmentation, 
and segmentation. (See Myocarditis.) Brown atrophy is common; 
the degenerated fibres are dark brown in color, contain yellow-brown 
pigments within the muscle-cells, and the cavities are decreased in 
size. An atrophy of the left ventricle is sometimes seen in cases of 
extreme mitral stenosis. Senile atrophy always accompanies fibrosis. 
Fibrosis occurs most often in the aortic valves; the corpora Arantii 
are first affected, laier the chordae tendineae become thickened, first 
at the valvular ends. Papillary muscles may also become markedly 
fibroid. fOsler.) 

As a result of degeneration spontaneous rupture may occur, usually 
in the anterior wall of the left ventricle. Tin's results from fatty in- 
filtration, degeneration, gumma, or tuberculosis. It has been found 
associated with abscess, aneurism, ulceration, myomalacia, arterio- 
sclerosis, and thrombosis. Fatty degeneration may end in rupture 
(spontaneous) of heart. Rupture may be <\uv to trauma. Blows upon 
the chest may rupture the heart and also cause localized myocarditis, 

9 



j^o POST-MORTEM EXAMINATIONS 

injury to mitral leaflets, or tear holes in valves where the chordae ten- 
dineae had been attached. This also occurs from extreme action or 
blows, gunshot wounds, etc. 

Aneurism of the heart itself is usually due to myomalacia, with 
thickening and narrowing of coronary arteries and chronic myocar- 
ditis, often associated with valvulitis, syphilis, etc. It occurs usually 
in the left ventricle near the apex, or may be found in the intraven- 
tricular septum or posteriorly. The endocardium is usually opaque, 
the muscles are sclerotic, and layers of thrombi are found in the sac. 
The aneurism may or may not be lined with endothelial cells. Two 
aneurisms may be found existing in one heart. Now and again an 
aneurism appears on the valves of the heart, and is then spheroidal and 
projects from the ventricular face of the semilunar valve. Literature 
is full of reported cases of cardiac and aortic aneurisms, there being 
several pages devoted to this subject in the Index Catalogue. 

Myocarditis. — In the myocardium large hemorrhages may be met 
with, as a result of the rupture of small aneurisms of branches of 
the coronary arteries or as a hemorrhagic infarct. Anaemic infarct 
may also be due to a partially obstructing embolus or the formation 
of a thrombus or to disease of the coronary artery. It usually occurs 
in the left ventricle, at the apex, or in the septum. It is irregularly 
shaped, yellow-white in color, and sometimes turbid or parboiled in 
appearance. This is a common cause of sudden death. Tardieu's 
spots, or small hemorrhages beneath the endocardium and at times 
extending into the muscle, are found especially after suffocation and 
in cases of rapid death from acute infectious fevers. Myocarditis 
usually is secondary to inflammation of the heart muscle. Parenchy- 
matous myocarditis may be diffuse or limited. When the inflamma- 
tory process involves all of the musculature of the heart, as is frequent 
in the infectious diseases, it is characterized at first by the flabbiness 
and the turbid grayish-red color of the heart muscle. In the later 
stages there is much fatty degeneration. Segmentary parenchymatous 
myocarditis is marked by a cloudy appearance of the heart muscle, 
which is flabby and friable. (Orth.) Fibres may separate at the 
cement line. Transverse fragmentation of the fibres is the form which 
usually occurs during the death agony. Acute circumscribed intersti- 
tial myocarditis, or abscess of the heart, is usually a part of a general 
pyaemic disease, with infection through the coronary circulation. 
These metastatic abscesses occur in cases of puerperal sepsis, with 



DISEASES OF THE HEART 1 ? > i 

osteomyelitis and other intensely septic diseases, but particularly in 
cases of malignant endocarditis. There may be only a few abscesses 
or the heart substance may be studded with innumerable suppurating 
points. In size the abscesses vary from the merest dots to cavities of 
the size of a cherry ; they may perforate or form ulcers in the cardiac 
wall. Acute diffuse interstitial myocarditis occurs in various forms 
of infectious fevers. The affected heart muscle is soft and often dis- 
tinctly friable; there may be spots of hemorrhagic infiltration, but, 
as a rule, the color is rather lighter than that of the normal organ. 
The cavities of the heart are frequently dilated, particularly the left 
ventricle. Chronic interstitial myocarditis or fibrous myocarditis may 
also be diffuse or localized, though the circumscribed form is the most 
common. The process is usually secondary, due to a primary disease 
of the coronary arteries, or to disturbances of the circulation therein, 
consequent perhaps upon old age, intemperance, gout, syphilis, and 
the like. This fibroid overgrowth is very commonly met with at the 
tips of the papillary muscles, on the trabecular, or in the substance of 
the cardiac muscle, and often at the apex of the left ventricle, where 
it may lead to such a degree of atrophy that a chronic localized aneu- 
rism of the heart may be formed by the constant pressure of the blood 
upon this thinned area. The heart is usually hypertrophied and the 
cavities dilated. The characteristic change is the formation of dense, 
grayish sclerotic areas, which appear either as more or less irregular 
spots or as streaks or lines running in the direction of the cardiac 
fibres. The entire substance of the heart may be involved and thick- 
ening of the walls may result. (Stengel.) The condition of soften- 
ing of the organ, or myomalacia cordis, has already been referred to. 
The degenerated tissue may form a scar, but more frequently leads 
to an aneurismal dilatation, which may subsequently rupture. Aneu- 
risms of the sinus of Valsalva may form and rupture in unexpected 
places; I have seen, for example, an aneurism of an aortic sinus rup- 
ture into the right ventricle. 

Endocarditis. — Disturbances of the circulation of the endocar- 
dium are rare, as this membrane possesses no blood-vessels of its own. 
A diffuse redness in this situation may. however, be the result of 
imbibition, and in the case of long-diseased valves, in which there arc 
newly formed blood-vessels, reddish streaks and spots may be ob 
served, which are due to small hemorrhages, Inflammation of the 
inner lining of the heart is frequently a secondary affection, dependent 



[32 POST-MORTEM EXAMINATIONS 

upon inflammatory disorders of other organs, such as suppurating 
wounds, purulent peritonitis, and pneumonia, or to rheumatism, gonor- 
rhea, chorea, tuberculosis, cancer, etc. The most common organisms 
found are the various forms of cocci. Sometimes, however, the endo- 
carditis is the first local manifestation of an infection, the exciting 
agent of which has left no recognizable traces at the seat of its entrance 
into the body. In the foetus endocarditis is usually situated in the right 
side of the heart, because the blood enters the organ on that side, and 
may be associated with lesions of the ductus Botalli. After birth the 
opposite condition prevails, the lesion being most commonly found 
on the left side. In the great majority of adult patients acute endo- 
carditis affects the endocardium of the valves only, — the mitral, the 
aortic, and the pulmonary valve in order of frequency ; but it is some- 
times found in the endocardium of the cavities of the heart, — in the 
left ventricle, the left auricle, and the right ventricle. Various names 
have been applied to these conditions, as simple, verrucose, benign, 
ulcerative, septic, mycotic, rheumatic, syphilitic, diphtheritic, fibrous, 
or malignant endocarditis. Such cases differ much in their appearance, 
even when produced by the same organisms. Endocarditis starts on 
the endocardium as a minute, roughened area, which is red in color 
and slightly elevated. This can easily be scraped off, but, if the spot 
where it was found is carefully examined with a hand lens, a small 
ulcer will be seen. More and more fibrin is now deposited, and the 
corpuscular elements are caught in its meshes ; the organisms multiply 
and the clot undergoes a liquefaction necrosis, the process not stop- 
ping in the newly formed tissue but often penetrating the valves or 
even the walls of the heart. Embolic occlusion of certain vessels and 
metastatic inflammations in other organs, especially the kidneys, spleen, 
brain, lungs, meninges, and skin, are not infrequently associated with 
endocarditis (Ziegler). Such hemorrhagic areas are to be sought 
for in the palpebral conjunctiva; their discovery therein during the 
external examination of the body has more than once led me to sus- 
pect ulcerative endocarditis, even when there was no clinical history 
of its existence. This previous observation is of special value when 
a bacteriologic examination of the heart is desired. These ulcerative 
areas of valves on healing are replaced by scar tissue, which, by con- 
traction and by various degenerative changes, such as necrosis, fatty 
degeneration, and calcification, give rise to the most fantastic shapes 
and appearances of the parts affected. Old cases are often associated 



DISEASES OF THE HEART I33 

with aneurism of the leaflets, dilatation, pouching, or perforation of 
valves. Often small tumor-like masses remain on the leaflets, which 
become thick, rigid, and calcareous. 

Hypertrophy axd Dilatation. — These conditions are usually 
associated the one with the other. In concentric hypertrophy the car- 
diac walls are thickened and the cavities are smaller than normal. As 
this may be due to post-mortem contraction or to marked systole, it 
may be well in some cases to soak the heart in tepid water before the 
measurements are taken. In simple hypertrophy the overgrowth of the 
walls is associated with normal cavities, while in eccentric hypertrophy 
dilatation is found along with the thickening of the walls. The highest 
degrees of enlargement which I have seen have been found in cases of 
double aortic disease, where, too, moderator bands are sometimes 
found. It would seem that the long-continued administration of digi- 
talis may produce hypertrophy. 

Valvular Diseases. — An extreme degree of mitral stenosis is 
seen in the so-called buttonhole mitral, a condition more frequently 
observed in England than it is in this country and which causes hyper- 
trophy and dilatation of the left auricle. Cyanotic induration of other 
viscera, especially of the lungs, and dropsical effusions may follow 
mitral incompetence. In aortic stenosis the valves are usually thick- 
ened, rigid, and cartilaginous; later they become calcified and the 
division between the different cusps is lost. First there is ventricular 
hypertrophy, later right-sided enlargement, and finally dilatation with 
pulmonary congestion. In aortic incompetency arteriosclerotic changes 
are marked, being seen not only in the valves but also in the aorta, and 
associated with dilatation and hypertrophy of the left ventricle and of 
the left auricle, and often followed by fibroid myocarditis. Sudden 
death is frequently due to aortic stenosis, a condition usually associated 
with hypertrophy of the left ventricle and a dilated cavity. The aortic 
ring and segments are atheromatous, puckered, and contracted, often 
calcareous, and may admit only the tip of the little finger. The aorta 
above the structure is usually dilated. Tricuspid regurgitation is seen 
generally associated with cases of cirrhosis of lung and chronic emphy- 
sema. Cyanosis is common. Pulmonary-valve disease is rare, except 
as a congenital lesion. Stenosis is usually associated with patency of 
the ductus Botalli. 

Syphilis, Tuberculosis. Actinomycosis, Tumors, etc. — Syphi- 
litic gummata appear in the heart as rather large yellow foci sur- 



134 



POST-MORTEM EXAMINATIONS 



rounded by fibrous tissue; they may also be found in the arch of the 
aorta. Miliary tubercles, when present, are usually subendocardial 
or situated in the large vessels coming off the heart. At a postmortem 
in Ziegler's mortuary I once saw where caseation of a peribronchial 
gland had extended through the pulmonary artery and given rise to a 
most marked local and general miliary tuberculosis. Actinomycosis 
has been observed. Tumors are rare ; myxomata, lipomata, fibromata, 
fibrous polyps, sarcomata, and rhabdomyomata may be met with as 
primary tumors of the heart, while, as secondary deposits, carcinomata 
and especially multiple melanotic sarcomata may be observed. (Plate 
IV. ) In v. Pessl's case 1 of extensive lymphosarcomatosis, the heart 
at autopsy showed the anterior wall of the left ventricle and a large 
part of the septum almost converted into a " shell of lime." A car- 
cinoma may thus develop here secondary to one of the penis. 2 Foreign 
bodies, as needles, hat-pins, pieces of bone, etc., have been found in 
the cardiac wall and even in the cavities of the heart. Cysticerci, 
echinococci, and very rarely pentastomata may be discovered in the 
various parts of the heart. 

Arteries, Morbid Changes in. — Arteriosclerosis. 3 — A chronic 
thickening and hardening, diffuse or circumscribed, of the arteries, 
characterized by a diminution of elasticity of the vessels and marked 
alterations in blood-pressure. The arch of the aorta is the most com- 
mon seat. In the first stage there are a loss of elasticity and some 
dilatation, due to hyaline or other changes in the subendothelial coat, 
and thickening of the intima. The second stage is characterized by a 
thickening of the media, atrophy of the muscular and elastic tissue, 
with proliferative changes in all the coats; the increase of new tissue 
gives rise to pressure on the vasa vasorum, with interference of nutri- 
tion, which leads to the third stage. New elastic tissue, derived from 
the splitting off of the internal elastic layer of the artery, may be found 
in the intima. This consists of more or less marked macroscopic 
changes. The vessels are hardened, firm to the touch, do not retract 
or close when cut, and their lumina may be smaller or larger than 
normal. On the intima may be seen milk-white or yellowish patches, 
containing fat, cholesterin, and detritus, intermingled with calcareous 

1 Munch, med. Wchnschr., June 10, 1902, p. 956. 

2 Pepper, Phila. Path. Soc, meeting of November 12, 1903. 

3 Welch's paper, read at the June, 1904, meeting of the American Medical Asso- 
ciation, should be consulted by those interested in this important subject. 






PLATE IV 



. 



2 -;> -0% 


























^""% 



2H 















12 



i, fibroma; 2. chondroma (after Ziegler) : .;. cavernous angioma of the liver; j. myoma : 5, glioma 
of the brain; 6, giant-celled sarcoma; 7. spindle-celled sarcoma; B, endothelioma of the pia mater; 
9. adenoma; 10. cancer; 11, epithelioma with an epithelial pearl; 12, myxomatous cancer. 



DISEASES OF ARTERIES I35 

plates and areas of ulceration. There may be a marked tendency to 
dilatation, with the formation of an aneurism, or to contraction with ob- 
literation. Some cases are associated with fibrosis of the aortic valves. 
As described by Heller, this form when found in the thoracic aorta is 
usually syphilitic. Special Forms. — (a) Senile. To a certain degree 
this may be regarded as physiologic, the elastica being developed as in 
scar tissue. The condition affects the larger arteries most; they are 
dilated, lengthened, tortuous, thin but stiff; often show atheromatous 
changes in the intima. Even to the naked eye the subendothelial tissue 
is degenerated. Cyanotic induration and senile atrophy of the heart, 
liver, and kidneys are common. Moist gangrene of the extremities 
may follow calcification in the iliac arteries. The changes produced 
by sclerosis of the coronary artery have already been referred to. (b) 
Xodular. Knob-like, flat, yellowish-white projections are seen in the 
aorta and its branches, particularly about the orifices. These in later 
stages undergo liquefaction and form atheromatous ulcers. Dilatation 
or aneurism may then ensue, (c) Diffuse. The lesion is wide-spread 
and more uniform ; the intima, as a rule, does not show marked naked- 
eye changes, though there may be elevated spots of an opaque white 
color. The aorta and its branches are dilated, the branches sometimes 
more than the trunk. Cardiac hypertrophy is constant. The kidneys 
are sclerosed, their capsule is adherent, the cortex irregular and often 
cystic, (d) Endarteritis obliterans. There is particularly a thickening 
of the intima, the entire lumen of the vessel being closed. It is not 
uncommon at the base of the brain. Erythromelalgia is largely due 
to arteriosclerosis. Lead and alcohol are considered to be frequent 
causes of arteriosclerosis. 

Amyloid Degeneration. — Usually microscopic, and best demon- 
strated by staining. Atrophy. — A general diminution in the size of 
arteries, best seen in stumps after operations. Calcareous Infiltration. 
— In the media of the arteries of the old, particularly involving those 
of the extremities, calcification of the media occurs. It interferes with 
the flow of the blood, predisposes to thrombosis, and may be the cause 
of senile gangrene. Seen as a diffuse or circumscribed process, usually 
in connection with atheroma, and as a later stage of fatty degeneration. 
Fatty Degeneration. — In fatty degeneration the affected areas of the 
intima have a white or a citron-yellow appearance. These areas occur in 
the form of points, stripes, and regular or irregular net-shaped figures. 
A frequent location is the posterior wall of the aorta around the origin 



1 36 POST-MORTEM EXAMINATIONS 

of the intercostals. For more careful macroscopic study the surface 
of the fatty area should be removed with a fine forceps and in the 
centre a shallow incision should be made. Here small and large fat 
droplets can be seen. When placed in Flemming's solution these drop- 
lets become black. The fatty degeneration may involve the media and 
even be the cause of rupture. Often associated with calcareous degen- 
eration. Hyaline Degeneration. — Almost always microscopic; affects 
mostly the elastic coat and is often the beginning of an arteriosclerosis. 
It most frequently involves the small arteries. Best seen in the glomer- 
uli of the kidney. Hypertrophy. — There is hypertrophy of the mus- 
cular layer in some diseases of the kidney, and hypertrophy of this 
layer in arteries of medium size in aortic insufficiency. A general en- 
largement, best seen in the collateral circulation after ligation of a large 
vessel. Hypoplasia. — Hypoplasia of the aorta is congenital and is the 
result of stenosis, most commonly situated near the insertion of the 
ductus arteriosus Botalli. It usually soon causes death; if not, the 
aorta is contracted and thinner, but very much more elastic. Virchow 
attributes chlorosis to it. 

Inflammations. — I. Acute endarteritis (proliferative or obstructive 
endarteritis, thrombo-arteritis ) . This starts with an injury to the 
endothelium, proliferation occurs, and an obstruction is formed in the 
vessel wall, on which a thrombus forms, partially or completely ob- 
structing the vessel. The intima is yellow and may be covered with 
many arcuate limited or confluent ulcers, with a loss of substance. 
Cholesterin and fat cells are found in the detritus. The lesion may 
terminate in absorption, suppuration, ulceration, or fibroid change. II. 
Chronic endarteritis. This usually follows the acute form, but is some- 
times primary. It may be local (organization of a thrombus) or gen- 
eral (arthritis deformans). Thrombosis is more common in the veins; 
it is usually caused by embolus from the right heart or from the left and 
associated with hemorrhagic infarct. Cases have been reported of 
thrombosis in the aorta above its bifurcation, in which the aorta and 
the femoral and popliteal arteries also revealed a marked thrombosis. 
It may occur in a vein during pregnancy, chronic nephritis, rheuma- 
tism, diphtheria, or typhoid fever. Marantic thrombi may form in 
cases of enfeebled circulation, as in the cachexia and anaemia of severe 
infections, sometimes associated with arteritis obliterans. In these 
cases it occurs usually in the large superficial veins of the lower ex- 
tremities and in the sinuses of the brain. Thrombosis of the superior 



DISEASES OF ARTERIES ^ 

mesenteric artery, with a slate-colored to black gangrene of the small 
intestines for many feet, is sometimes seen. The thrombi are gray- 
white, red., or mixed; if recent, they are attached, of bright-yellow 
color and membranous consistency; if old, they are firmly organized 
and may be calcareous. Thrombus is generally supposed to be due 
primarily to bacteria. Thrombi are not at all rare in the heart, occur- 
ring usually in the auricle of the right side or the apices of the ven- 
tricles between the papillary muscles. They often have a root-like 
process, which is especially marked in the appendix, and are most 
frequently found in cases of cardiac aneurism and in endocarditis. 

SypJiilis is usually a diffuse process affecting all the coats, espe- 
cially the mtima, and thus giving rise to a local or general sclerosis. 
Gummata are rare. Orth, quoting from Heller, gives the numerous 
small foci of cell-infiltration necrosis, and particularly induration, with 
small thickenings of the inner surface, as the characteristic differences 
between syphilis and chronic aortitis. 

Tuberculosis. — Tuberculous lesions are less common in the arteries 
than in the veins. The small arteries are most frequently affected, as 
those of the pia, the brain, the kidneys, and particularly the lungs. 
The disease starts as a local gray tubercle of hsematogenous origin in 
the intima or as an extension from a neighboring tuberculous process. 
Thrombosis and embolism, especially in the brain, are of extreme im- 
portance. In embolism air, fat, portions of tumors, micro-organisms, 
etc., are brought to a smaller vessel from a larger one (though the 
converse may occur), and there set up characteristic changes, as in- 
farcts, softening, abscesses, etc. 

Tumors. — The new growths found in arteritis are angioma, an 
erectile tumor ; the capillary naevus is usually found on the face, capil- 
laries dilated and tortuous; if made up of dilated and tortuous arteries 
it forms a racemose or cirsoid aneurism and is usually seen in the 
subcutaneous tissue. The skin over the tumor is, as a rule, very much 
thinned. An arterial varix consists of a dilatation and lengthening of 
a single artery. Venous naevus is a tumor made up of communicating 
spaces lined with endothelium into which arteries empty and from 
which veins arise. 

Aneurism. — An aneurism is a circumscribed, tumor-like dilatation 
of an artery, containing blood in direct connection with the blood- 
current. A true aneurism has a sac composed of one or more <>f the 
arterial coats. A false, spurious, or hernial aneurism is one in which 



138 POST-MORTEM EXAMINATIONS 

some of the walls are formed by the tissues surrounding an opening 
in the artery; these sometimes attain an enormous size. The aneurism 
is called cylindrical when there is widening in all directions; saccular 
when one side is affected ; cirsoid when a large extent, or even the whole 
ramification, of an artery becomes dilated and tortuous; this form most 
often occurs in the frontal, occipital, or iliac arteries ; fusiform when it 
is spindle-shaped ; sometimes these form near a tear of the intima, the 
media and adventitia becoming markedly sclerosed (arteriosclerotic). 
A traumatic aneurism results from injury or laceration of the intima 
by force. A dissecting aneurism arises when blood circulates between 
the coats of an artery. Extensive degeneration must precede this form. 
I have seen such an aneurism beginning at the transverse arch of the 
aorta and opening again into the blood-stream just above the aortic 
bifurcation. Arteriovenous aneurism arises where there is a communica- 
tion existing between an arterial aneurism and a vein ; a variety of this 
is the varicose, where an artery and a vein communicate through a 
false aneurism lying between them. When bleeding was more fre- 
quently practised than it is now, these aneurisms in the arm were of 
quite common occurrence. Mycotic or infective aneurisms are mul- 
tiple and are caused by micro-organisms. This variety is often seen 
in connection with malignant endocarditis. The mesenteric arteries 
of the horse sometimes become dilated with considerable numbers of 
the Strongylus annatus. Miliary aneurisms are usually multiple and 
consist of small dilatations; they are found especially in the brain 
and lungs and often antedate a hemorrhage in these regions. They 
are best seen in the brain by excising the middle cerebral or basilar 
artery and floating it out in a white dish partially filled with water. 
These aneurisms may be due to emboli. Traction aneurisms have 
been reported by Thoma at the concavity of the arch of* the aorta. 
Aneurism by distention, rupture, erosion, anastomosis, also valvular 
and congenital aneurisms have been described. Aneurism is often asso- 
ciated with arteriosclerosis, embolism, trauma, and infections. The 
change is now believed to start in the elastic coat. 

The walls of the blood-vessels may be present or altogether absent ; 
they may be thickened and opaque or almost transparent. If the aneu- 
rism be large, the cavity has a roughened wall, often lined with endo- 
thelium, and frequently contains clots which are white, red, organized, 
or softening. They often show lamination. I have seen a fibrinous 
clot of an aneurism of the carotid mistaken for a sarcoma of the neck, 



DISEASES OF VEINS I ^g 

a gluteal aneurism opened for an abscess, and a femoral aneurism 
mistaken for a hernia. Rupture of an aneurism, usually from the 
aorta into the pericardium, is a most frequent cause of death in cases 
brought to the notice of the coroner. The rupture often occurs during 
the act of defecation. Three cases of aneurism of the sinus of Val- 
salva have come under my notice. The direction of the increase in 
size of a forming aneurism depends on its location. Constant pressure 
of the sac may overcome the resistance and cause absorption of the 
densest tissue, even bone. Hence aneurisms of the arch of the aorta 
may rupture externally or erode the vertebral column. It is the sac- 
culated aneurism which is now treated by electrolysis. Life may thus 
be prolonged, though the aneurism usually appears in another spot. 
In Stewart's case life was prolonged three and a half years, the man 
finally dying from an alcoholic pneumonia. The clot around the gold 
wire may become markedly fibrinous. The danger in the operation 
would seem to be from an embolus. Aneurisms are most common in 
the thoracic aorta, abdominal aorta, cceliac axis, splenic artery, very 
rare in the hepatic artery. I have seen a few cases of that rather rare 
condition, aneurism of the superior mesenteric artery. 

Congenital aneurism, periarteritis nodosa, closely resembles at times 
sarcoma; nodules may be felt in the abdominal wall, in arteries of 
muscles, and in the viscera. There is marked thickening of the intima 
and infiltration of other coats. 

The question as to the etiology of aneurism is much debated. My 
own statistics on this subject confirm the opinion that syphilis is a fre- 
quent cause, especially in the early stages before marked arteriosclerotic 
changes have taken place in the arteries. This view is also supported 
by the fact that animals are rarely affected with aneurism. The ex- 
perimental production of aneurism in animals by alcohol, trauma, etc., 
affords an interesting field for future investigators. 

Diseases of Veins. — The more common lesions in veins are 
thrombosis and phlebitis. Phlebitis occurs in connection with many 
cases of thrombosis, in gout, and after traumatism; micro-organisms 
are usually found. It appears commonly in sinuses of the brain, asso- 
ciated with leptomeningitis. The intima is rough, uneven, corroded. 
Vein walls are infiltrated and discolored. On the surface over an in- 
fected vein there is a dusky-red line. Thrombosis always occurs. Sup- 
puration or pylephlebitis, associated with thrombosis and with purulent 
softening, occurs in the portal veins. The vein is filled with puriform 



I 4 POST-MORTEM EXAMINATIONS 

fluid, which may cause a branching- abscess all through the liver. A 
varix is a permanent dilatation above a valve, — long fusiform dilata- 
tion (phlebectasia) or cirsoid aneurism. It is most common in the 
leg and is often associated with diseases of the heart, liver, lungs, 
pleura, or may be caused by pressure of a tumor. Phlebosclerosis is 
seen at times with dilated veins. The vein in these cases is nearly 
always distorted and thickened. Thrombi often form in dilated parts 
and are sometimes converted into phleboliths. Associated with this 
lesion are oedema, chronic catarrh of a mucous surface, chronic ulcera- 
tion of a cutaneous surface, pigmentation, and productive fibrosis. Cer- 
tain varices have special names, as varicocele, dilatation of spermatic 
veins; hemorrhoids, dilatation of veins of lower rectum; caput me- 
dusae, dilatation of superficial abdominal vessels, etc. Primary tumors 
are rare in veins. Any tumor may be present secondarily. Often 
there is a fibrous endophlebitis, etc. Syphilitic inflammation is seen 
in portal and other veins and is a congenital form. Tuberculosis of 
a vein from a lymph-node is not uncommon in general miliary tuber- 
culosis. 

Chief Lesions Found in Lymph-vessels. — Dilatation is espe- 
cially seen in elephantiasis Arabum and is due largely to filaria. Cer- 
tain parts, as the scrotum, labia, and thigh, are generally the seat 
of the lymph stasis. This lesion is always associated with hypertrophy 
and thickening of the tissues. Lymph tumors (lymphangioma) — (i) 
simplex, not much enlarged, (2) cavernosum, much dilated — are 
usually found in the tongue (macroglossia), cheek, etc. Lymphan- 
gioma cysticum occurs most frequently in the neck or the sacral region. 
Contents of the cyst are often very fatty, at times partially coagulated. 
Endothelioma and carcinoma may occur. The lesions of tuberculosis 
and syphilis are found. 



CHAPTER IX 

DISEASES OF THE RESPIRATORY TRACT AND ACCESSORY PARTS 1 

Nasal Passages. — Malformations of the nose are very common. 
The entire nose, the septum, or the turbinates may be absent. Devia- 
tion of the septum occurs in about one out of every ten persons. 
Acute Nasal Catarrh (Rhinitis, Coryza). — This condition accompanies 
various infections, as variola, scarlatina, measles, influenza, rotheln, 
and diphtheria. In infants it is often a manifestation of syphilis or 
gonorrhceal infection. The nasal mucous membrane is red, swollen, 
and covered with exudate, the accessory sinus, pharynx, and Eustachian 
tubes being sometimes secondarily inflamed. Empyema of the antrum 
of Highmore may result, but more frequently arises from carious teeth. 
Herpetic eruptions are often seen on the lips. Chronic Nasal Catarrh. 
— Varieties : hypertrophic, atrophic, fibrinous, or membranous. There 
is usually a persistent mucopurulent discharge. In the hypertrophic 
form there are flattening of the nasal bridge, thickening of the alae and 
the mucous membrane, exostoses on the septum, and hypertrophy of 
the cavernous tissue. In the atrophic variety the mucous membrane is 
pale, dry, glazed, and covered with scabs, ulcers, and, at times, necrotic 
tissue, which may lead to perforation of the septum, but this is much 
more commonly seen in syphilitic rhinitis. Adenoids are, as a rule, 
confined to the roof of the nasopharynx, but may occur upon the lateral 
walls. They are smooth, rounded masses, or pedunculated, varying 
in size from a hemp-seed to an almond and of a pale-pink color. These 
may replace entirely the normal pharyngeal tonsil. Nasal tuberculosis, 
especially in the form of lupus, syphilis, glanders, and leprosy, may 
occur in the nose. Rhinoscleroma gives rise to nodular thickenings 
and ulcerations of the tissues of the nose, lips, pharynx, and larynx. 
Tumors. — Fibrous, myxomatous, and cystic growths arc by far the 
most common varieties found in the nose, and arc most commonly 
situated in the lower third of the chamber. Cysts, fibroma, fibro- 
myxoma, chondroma, osteoma, epithelioma, and angiosarcoma arc seen. 
Sarcoma usually affects the nares and ethmoid cells. Carcinoma is 
rare. Rhinoliths are sometimes discovered measuring an inch or more 



'Based on AlXCHIN's Manual of Medicine, I 

[41 



I 4 J POST-MORTEM EXAMINATIONS 

in length and nearly as broad. They are quite thin and easily broken 
in their removal. Especially in childhood foreign bodies, such as food, 
coins, seeds, which may sprout, eggs, especially of certain flies, which 
may here assume the larval form, buttons, rags (especially in the new- 
born), blood, vomit, and pus, may be discovered. 

Hay Fever. — An asthmatic disorder manifesting itself by paroxys- 
mal attacks of nasal catarrh with marked periodicity, the attacks being 
induced by certain localities, odors, the pollen of many plants, dust, 
etc. The nasal mucous membrane shows usually some abnormality 
or chronic hypertrophic rhinitis, with free exudation, poly-septal irregu- 
larities, adenoids, and turgescency of the mucous membrane, especially 
over the inferior and middle turbinates. 

Epistaxis. — Bleeding may be due to acute or chronic rhinitis, 
ulceration of the nasal mucous membrane from tuberculosis, syphilis, 
diphtheria, or foreign bodies, and is very common in malignant new- 
growths and in valvular disease. 

Larynx. — The larynx is frequently deformed from hypoplasia or 
asymmetrical development. The sinus of Morgagni may be dilated 
or there may be fistulous canals from imperfect closure of bronchial 
clefts. Acute catarrhal laryngitis is usually secondary, following in- 
fections, as measles, typhus, smallpox, whooping-cough, etc. The 
vocal cords are reddened, swollen, and covered with viscid mucus. 
In very severe cases erosions and ulcers are observed. Varicose veins 
and punctate hemorrhages are seen, especially in chemic cases. Diph- 
theritic laryngitis is generally a part of a general infection. The 
mucous membrane is covered by a gray-yellow membrane, under which 
the epithelium is eroded and necrotic. Erysipelas also affects the 
larynx. (Edematous laryngitis may be acute or chronic, and is due 
to septic infection, traumatism, certain drugs, or chronic visceral dis- 
eases, — e.g., Bright's disease. This may be inflammatory, non-inflam- 
matory, or dropsical. ( I ) ,The epiglottis, the aryepiglottic folds, and 
the ventricular bands are the parts chiefly affected. The vocal cords 
are seldom included, but the cedema may go below them. The mucous 
membrane is pale, except at the borders of the swelling, which are 
injected. (2) The exudation may be serous, seropurulent, or purulent, 
and may or may not be blood-stained. (3) In very severe cases the 
larynx may be entirely closed, and the mucous membrane swollen and 
reddish purple, the epiglottis appearing as a round, translucent tumor. 
In chronic laryngitis the mucous membranes are reddened, the cords 



DISEASES OF THE RESPIRATORY TRACT ^3 

are thickened, sometimes with adherent secretion, and the vessels are 
injected. In laryngitis sicca the cords are covered with dry crusts, 
which may be blood-stained. Pachydermia laryngis is a condition in 
which symmetrical fleshy-looking thickenings are found on the cords. 
Singers' nodes resemble these and are round nodules on the upper 
surface and free border of one or both cords. Perichondritis is always 
secondary, the lesion appearing first as a smooth, nodular, unilateral 
swelling, which is soon followed by necrosis or abscess, most often 
involving the cricoid. It is a common manifestation of syphilis or 
malignant disease. This may be followed by ankylosis of the crico- 
arytenoid joint, which is associated with tumefaction, abnormal posi- 
tion of the arytenoid cartilages, and fixation of the vocal cords, or by 
laryngeal stenosis. This is also secondary to healing of tuberculous, 
syphilitic, or chemic ulcers, pressure of foreign bodies, etc. In one 
case a fish-bone was found, transverse in the larynx, resting on the 
ventricular bands and arytenoid cartilages. 

Tumors of the Larynx. — Benign growths are quite frequent. There 
is usually a diffuse hyperemia or a warty or infiltrating growth on one 
cord, situated about the middle and surrounded by a zone of conges- 
tion. Ulceration, perichondritis, and exfoliation of the cartilages are 
common complications. The most common tumors are papilloma, pap- 
illary fibroma, and fibroma tuberosum. The malignant tumors are car- 
cinoma, sarcoma, and epithelioma. Foreign bodies, inducing suffoca- 
tion, are by no means uncommon. I have known a piece of lead-pencil 
and a bolus of food thus to cause death. 

Tonsils. — These glands are inflamed in the course of many in- 
fections and may be primarily affected, as with tuberculosis, gangrene, 
syphilis, and lacunar keratosis. In simple catarrhal inflammations the 
tonsils are uniformly swollen, red, and covered with tenacious mucus. 
In the follicular variety yellow plugs of degenerated epithelium are 
held in the crypts by the swelling of the gland. In the phlegmonous 
form the tonsils may be so swollen that they meet and occlude the 
pharynx and may be yellow from the contained pus. Hypertrophied 
tonsils are manifestations of chronic inflammation, and are often asso- 
ciated with rickets, tuberculosis, adenoids, and chronic nasopharyngeal 
catarrh. There may be a true hypertrophy or overgrowth of but one 
tissue. The follicles may be dilated and filled with cheesy material. 
Sarcoma is a not uncommon tumor. Epithelioma, angioma, fibroma, 
myoma, papilloma, and lymphoma occur. Bone and cartilage are 



144 



POST-MORTEM EXAMINATIONS 



Tim: TRACHEA AND Bronchi. — Malformations. — Fistula is due to 
imperfect closure oi the third and fourth branchial clefts, a small orifice 
remaining, which may communicate with the trachea or end blindly, 
on the anterior edge of the sternomastoid muscle three or four centi- 
metres above the inner end of the clavicle. The inner portion is at 
times dilated, forming a bronchiogenic cyst. 

Asthma. — This condition being due to a spasmodic contraction of 
the bronchial tubes and air-vesicles, the lesions found at the post- 
mortem are not marked, consisting only in hypertrophy and widening 
of the bronchial tubes with thickened mucous membrane and a dila- 
tation of the air-cells, giving the chest a barrel-shaped appearance and 
the dorsal spine a curvature. Pressure on the vagus by enlarged bron- 
chial glands is sometimes the only lesion found, or it may be asso- 
ciated with hypertrophic rhinitis. Charcot-Leyden crystals and Cursch- 
mann's spirals are often discovered in the sputum. 

Bronchiectasis. — There is a local or general dilatation of the bron- 
chial tubes, which may be congenital and unilateral or the result of 
various diseases of the lungs and bronchi. A non-patulous bronchus, 
closed alveoli (atelectatic bronchiectasis), puckering of the peribron- 
chial or interstitial fibrous tissue, parenchymatous changes of chronic 
bronchitis, or the circumscribed narrowing of tumors, etc., sometimes 
produce it. Cylindrical or uniform, saccular, spherical, ovoid, fusi- 
form, and moniliform dilatations are seen. At the postmortem large 
sacs may be situated immediately beneath the pleura or a number of 
sacculi varying in size may be found opening one into another. The 
walls are covered with smooth, glistening, or hypertrophied epithelium, 
which may be ulcerated in the dependent portion. Putrefaction (putrid 
bronchitis), fatal gangrene, or a tuberculous lesion may follow the 
retention of the material thus collected. Calcification sometimes occurs. 
The lungs usually show some fibroid change. The air-vesicles are 
emphysematous or condensed by pressure. The liver, spleen, and kid- 
ney often show chronic congestion or lardaceous degeneration. Pleu- 
ritic abscesses, peritonitis, adhesive pericarditis, dilatation of the right 
heart, etc., are complications which are sometimes found to be present 
in bronchiectasis. 

Bronchitis. — Bronchitis is an acute, subacute, or chronic inflam- 
mation of the bronchial tubes, not involving the terminal bronchi, due 
to infection, exposure, irritants, or extension from neighboring organs. 
Tn acute catarrhal bronchitis the mucous membrane is thickened, 



DISEASES OF THE RESPIRATORY TRACT I45 

swollen, at times hemorrhagic, and at first covered with tenacious 
mucus, which later becomes profuse, thin, and purulent, and may fill 
the large bronchi. Lobular atelectasis surrounds the affected areas. 
Suppurative bronchitis results from septic embolism, forming small 
abscesses in the bronchial tubes. Croupous bronchitis is characterized 
by the formation of a diphtheritic membrane, sometimes of complete 
casts of the smaller bronchi, but is not, as a rule, associated with the 
Klebs-Lofrler bacillus. Bronchopneumonia, extension to the small 
bronchioles and air-vesicles, oedema, congestion, and local emphysema 
are frequent complications. In chronic hypertrophic bronchitis the 
whole lung is larger, firmer, and darker than normal. The mucous 
membrane is thickened, reddish or slate-gray in color, and often shows 
petechial hemorrhages. The bronchus is sometimes dilated, or is 
thicker and more fibrous, with its lumen narrowed by small, firm, vil- 
lous granulations. This obliterating fibrous inflammation usually 
affects the smaller bronchi and may cause stenosis. The surrounding 
lung is usually emphysematous, pigmented, and shows an increase of 
fibrous tissue. The bronchial glands are enlarged, indurated, and pig- 
mented. Dilatation of the right heart and chronic congestion of the 
Fiver, spleen, and kidneys are common complications. The lung of 
atropine bronchitis is smaller and lighter in weight and color. Its 
elasticity is impaired, it feels " cottony" to the touch, and there may 
be increase of connective tissue, the longitudinal bands of elastic tissue 
standing out prominently. The mucous membrane is smooth, atro- 
phied, and the lumen of the tubules may be widened. Putrid bronchi- 
tis is practically a bronchiectasis. The bronchi are dilated; their walls 
are usually smooth, but are frequently ulcerated. Fatty plugs and puru- 
lent masses such as are found in the sputum during life are seen in the 
ulcers. Purulent oedema of the lung is more or less general. Plastic 
(fibrous) bronchitis may be regarded as a chronic form of croupous 
bronchitis, occurs only rarely, and is paroxysmal, usually being limited 
to a certain number of bronchi. The membrane is a fibrous, fairly con- 
sistent pseudomembrane about two millimetres thick with no epithelium 
under it. The mucous surface is hypersemic and infiltrated with cells. 
The thick ducts of the glands push the fibrous tissue <>ft and it is 
coughed up. The smaller bronchi show catarrhal inflammation, but 
no membrane. Sometimes coagula are found in the tubes after death. 
Tuberculous bronchitis may be acute, manifesting itself as a part of 
a diffuse caseous process and involving an entire wall (peribronchitis) 



1 4 (> POST-MORTEM EXAMINATIONS 

or appear as tuberculous ulcerations like those of the larynx. Cheesy 
bronchitis is a caseation of retained catarrhal secretion. The mucous 
membrane is infiltrated with cells and these also subsequently caseate. 
Gangrenous bronchitis is associated with bronchiectasis. 

Stenosis of the trachea or bronchi is due to pressure from tumors, 
aneurisms, mediastinal abscesses, hemorrhages, swelling of the lining 
mucous membrane, impacted foreign bodies, etc., to perforating case- 
ous glands or to contraction from syphilitic or tuberculous ulcers. 

Primary tumors of the bronchi are rare. Carcinoma may develop 
from the muciparous glands of the bronchial mucous membrane. Sec- 
ondary tumors are more common. Calcareous, papillomatous excres- 
cences, annular in shape, may be found in the trachea. Foreign bodies 
in the air-passages are discovered usually in the right bronchus. 
If the blocking is partial, vesicular or interstitial emphysema results. 
(Edema, local inflammation, and ulceration of the bronchus, lung, and 
pleura, with rupture of vessels, may occur. 

Diseases of the Mediastinum. — Mediastinitis is rare, and when 
present is generally due to infection by Pneumococci. The cellular 
tissue is infiltrated with a puriform lymph. Pericarditis, pleurisy, ab- 
scess, gangrene, ascites, cedema of the upper part of the body, and 
albuminuria may follow mediastinitis. Mediastinal adenitis may be 
simple, suppurative, or tuberculous. The simple form occurs with any 
inflammation of the neighboring organs. Suppurating glands may 
rupture into the oesophagus, bronchus, or aorta. Tuberculosis of 
glands is usually a secondary involvement from the bones, lungs, or 
pleura. The spindle-celled sarcoma is the most common growth in 
this region. Carcinoma, lymphoma, and lymphosarcoma are also 
found. Dermoid cysts have been reported as occurring in the anterior 
mediastinum. 

Goitre. — A local or general hypertrophy of the thyroid gland, 
characterized pathologically by a variety of morbid changes. In the 
same gland may be found cystic disease and mucoid, fatty, gelatinous, 
or colloid degenerations. On section the gland appears as a yellow 
or brownish mass with scattered areas of colloid matter, varying in 
size from a pin-head to a millet-seed. In cystic goitre there is a distinct 
limiting membrane, brownish red if the cyst be due to hemorrhage. 
If slender masses of tissue project from this membrane, the condition 
is known as papillary cystadenoma. In some cases the enlargement 
of the gland may be due to marked vascular dilatation without the 



DISEASES OF THE LUNGS i^y 

formation of new gland-tissue. If the arteries only are dilated, Orth 
calls it struma aneurysmatica; if the veins only, struma varicosd. 
Fibroid or calcareous changes also occur. In fetal adenoma the struc- 
ture maintains its fetal characteristics, — i.e., solid masses or rosettes 
of epithelial cells with little or no colloid material are seen. 

Goitre, Exophthalmic (Basedow's or Graves's Disease). — A dis- 
ease common to women of early adult or middle life, which is char- 
acterized by functional disturbance of the heart (diffuse or unilateral) ■, 
hypertrophy of the thyroid gland, rarely as great as in ordinary goitre, 
a marked increase in the number and size of its blood-vessels, absorp- 
tion of its colloid material, a replacement of it by a more mucinous 
fluid, and undue prominence of one or both eyes, due to an increase 
of the orbital fat. The thymus gland may persist and undergo en- 
largement, and there is an increased amount of connective tissue in 
the neck. Marked pigmentation of the skin may simulate Addison's 
disease. Myxcedema may develop in the later stages or the emaciation 
may be extreme. Glycosuria and albuminuria are not infrequent. The 
heart is usually hypertrophied, but may be dilated or even normal in 
appearance. 

Luxgs. — Abscesses. — Abscesses of the lung and neighboring parts 
may arise from pyaemia, embolism, tuberculosis, pneumonia, or the 
presence of foreign bodies, and are due to many varieties of bacteria, 
as pneumococci, tubercle bacilli, gonococci, actinomycetes, and various 
pyogenic micro-organisms. An abscess may discharge itself through 
a bronchus or otherwise and leave only a dense cicatrix. The solitary 
abscess is comparatively rare, and usually results from disease of the 
neighboring parts, as the pleura, liver, or mediastinum. Such an ab- 
scess may become encapsulated and contain a greenish-yellow pus of 
an offensive odor. Multiple abscesses are common, generally super- 
ficial, frequently wedge-shaped, rarely encapsulated, and vary in size 
from that of a pea to an orange. They are at first firm, grayish red in 
color, and surrounded by a zone of hyperemia. Later they become 
distinctly purulent, with an irregular, ragged cavity. The pleura is 
usually covered with a greenish lymph and may be perforated, causing 
an empyema, pyaemia, or septic pleuritis. Such abscesses often have 
their origin in a septic condition following criminal abortion. 

Atelectasis. — Collapse of the lung, partial or total, may exist in 
the foetus at birth f fetal atelectasis), or be caused by closure of the 
bronchi (capillary bronchitis ), compression from a tumor, hernia of the 



I4 8 POST-MORTEM EXAMINATIONS 

diaphragm, pleuritic transudates and exudates, or marantic conditions. 
The last is due to weakness and is most marked in the smaller ramifi- 
cations of the lower and posterior bronchi, often ending by subsequent 
(.edema in pulmonary splenization. The air in the shut-off portion 
is absorbed, and the portion on section is dark red or bluish red and 
firm. In old cases the lungs cannot be inflated, the tissue is dense, 
firm, deeply lobulated, and paler than the rest of the lung. The lung 
is usually atrophied or may be entirely replaced by a fibrous cicatrix. 
When the collapse is superficial, as in rickets or pleurisy, the lung is 
reduced in bulk and wrinkled, fleshy in appearance, smooth, tough and 
inelastic, and dark red in color. If due to bronchial obstruction, scat- 
tered patches of atelectasis occur over the lung, the bronchi leading to 
these areas being filled with mucopurulent secretion. The surrounding 
lung may be cedematous or perhaps the seat of chronic pneumonia. 

Circulatory Disturbances. — Anaemia, hemorrhage, infarcts, fat em- 
bolism, or even air embolism, of the lungs may be associated with a sim- 
ilar condition in the right heart. A number of fatal cases of pulmonary 
embolism have occurred after intramuscular injections of calomel for 
syphilis, caused by detachment of clots from the femoral, iliac, or uterine 
arteries, by hydatids, and by phlebolites. Fat embolism of the lung 
should always be thought of in cases of fractures or of extensive inju- 
ries to the subcutaneous fatty tissues or traumatic rupture of the liver. 
Haemoptysis may occur from hemorrhagic infarcts, brown induration, 
tuberculosis, an aneurism rupturing in the trachea or bronchi, acute in- 
flammations, purpura, scurvy, etc. It is interesting to note that a pul- 
monary hemorrhage in tuberculosis may be the beginning of an attack 
or precede a fatal termination. Pulmonary thrombosis may arise from 
embolus, engorgement of the capillaries, or disease of the pulmonary 
artery. It is not an infrequent complication in pneumonia and tu- 
mors, and often occurs in cases of atheroma of the pulmonary artery. 
Thrombosis of a pulmonary vein has been reported, usually the result 
of gangrene, pleurisy, or oedema. Hemorrhage into the air-cells and 
lung-tissue is due to thrombosis or aneurism of the pulmonary artery 
or to aspiration, as in gangrene and tuberculosis, or to the hemorrhagic 
diathesis. The extent of lung tissue involved differs very greatly. 
The lung is large, firm, dark, and heavy. On section there is ex- 
travasation of considerable amounts of more or less frothy fluid blood. 

Passive congestion occurs where there is obstruction of the circu- 
lation, in chronic illness requiring the recumbent position, and in dis- 



DISEASES OF THE LUNGS I49 

eases of the central nervous system. It is basic or hypostatic, (a) 
In mechanical congestion, if the condition has lasted some time, the 
lungs are voluminous, russet-brown in color, (edematous, and cut and 
tear with difficulty, giving rise to the so-called brown induration. On 
section they are of a maioon tinge, which on exposure to the air soon 
gives place to a vivid red. The alveolar capillaries are distended and 
tortuous, the fibrous tissue is increased, and haematoidin deposits are 
found in the epithelial cells, (b) In hypostatic congestion the bases 
of the lungs are deeply cyanosed and heavy and the posterior parts 
engorged with blood and serum. In some instances portions of the 
tissue will sink in water and on section exude a bloody serum. In pro- 
longed coma the hypostatic congestion may be associated with patches 
of consolidation due to the aspiration of food into the air-passages. 
(c) Passive congestion occurring in cerebral apoplexy is most marked 
in or may even be confined to the paralyzed side. 

Notwithstanding its ample collateral circulation, the lung is fre- 
quently the seat of small or large infarcts, especially of the hemorrhagic 
variety, usually situated peripherally and associated with brown indura- 
tion. They may be single or double. Thrombus, rupture from over-dis- 
tention, and infection of an embolus are the most common causes of this 
condition. "When recent the infarcts are dark red, firm, resistant, and 
vary in size, sometimes occupying the greater part of a lobe. Slough- 
ing and gangrene may follow. The pleura is congested and covered 
with exudate, the branches of the artery going to the lesion being filled 
with clotted blood. In old cases a pigmented scar may alone show 
the seat of a former infarct. 

Pulmonary oedema, which is a transudation of serum into the al- 
veoli and their walls, may be general or confined to the bases of the 
lungs. The organ is bulky, heavy, and pale, and pits on pressure. In 
some cases there is a partial consolidation, the lung appearing gelati- 
nous and containing less air than normal. On section it exudes a clear, 
frothy serum. The dependent parts may be red in color and boggy. 

Emphysema. — The dilatation of the air-vesicles is due to some 
weakness of the lung structure, as a congenital absence of elastic tissue, 
atrophy of the diaphragm, etc., and a dilating force, usually expiration, 
as chronic cough, certain occupations, etc. It may follow senile changes 
or a traumatism. The thorax is barrel-shaped and increased in its 
anteroposterior diameter. The clavicles, the sternum, and the costal 
cartilages are prominent. The intercostal spaces are enlarged and the 



i5° 



POST-MORTEM EXAMINATIONS 



sternal fossa is deep. The back is rounded and the curve of the spine 
increased. The neck appears to be shortened. Dilated veins may be 
seen along the line of the attachment of the diaphragm. On removing 
the sternum, the anterior mediastinum is found completely occupied 
by pulmonary tissue, the pericardial sac being entirely covered; the 
lungs are large, light in color or only slightly pigmented. They are 
inelastic, do not collapse, but pit readily on pressure. To the touch 
they are soft like feathers; expulsion of the air causes a crackling 
sound, and a paper-thin tissue remains. The edges are rounded and 
obtuse. Beneath the pleura, especially about the anterior margins 
and the inner surface of the lobe near the centre, enlarged air-vesicles 
of a delicate bladder-like appearance may be seen, varying in size 
from that of a pea to a hen's egg (bullous emphysema). Amyloid 
bodies are sometimes found loose or embedded in the walls. Local 
emphysema is common around old fibroid or tuberculous lesions, the 
dilatation affecting also the bronchi. In the atrophic form, really a 
senile atrophy, the lungs are small, pale, dry, and pigmented, pit on 
pressure, and collapse when the thorax is opened. The chief seats 
are at the edges and the apices. The mucous membrane of the large 
bronchi may be rough and thickened; bronchiectasis may be present, 
and the lungs irregular in shape. The right heart is dilated and 
hypertrophied ; the pulmonary artery is enlarged and atheromatous. 
Emphysema may be vesicular, being confined within the dilated alveo- 
lar spaces, or it may be interstitial, the alveolar walls being broken. 
This is seen especially beneath the visceral pleura and may be pro- 
duced post mortem by decomposition. 

Gangrene (Pnenmomalacia) . — Gangrene may be circumscribed 
or diffuse, and affects usually the peripheral portions of the lower 
lobe rather than the central. It is by some supposed to be due to 
a specific bacillus. The gangrenous part is large, firm and solid or 
of a pulpy consistence, heavy, and of an ash-gray to greenish-black 
color. The outer tissues are intensely cedematous, next is an area 
of deep congestion, and then a cavity with shreddy, irregular walls 
containing a greenish fluid of a most offensive odor. The pleura 
may be inflamed and contain an abnormal amount of exudate, or it 
may be perforated, causing a pyopneumothorax. The gangrenous 
material gives rise to an intense bronchitis, the bronchial tubes being 
obstructed by a thin, highly offensive pus or by mucus containing 
fatty acids, tyrosin, and leucin. The elastic threads disintegrate later 



DISEASES OF THE LUNGS IC - I 

than the remaining tissue, a fact of considerable diagnostic value. 
Embolic processes are common, abscesses of the various organs, espe- 
cially the brain, being the result. 

Parasites. — Certain parasites may infest the lungs. The Asper- 
gillus niger and fumigatus are sometimes found in these organs, 
always associated with a pneumomycosis, and the Mncor mucedo, a 
yeast fungus, in cases of cancer. Cysticercus cellulose, strongylus, 
and Distoma haematobium are now and again found. Mackenzie 1 re- 
ports a case in a Japanese from Portland, Oregon, of parasitic hemop- 
tysis or infection with the Distoma Wcstcrmanii. 

Pneumonia. — The chief forms of pneumonia are catarrhal (bron- 
chopneumonia), chronic interstitial, and lobar (croupous and fibrin- 
ous). In cattle there is also found a very infectious variety known 
as pleuropneumonia. Catarrhal pneumonia is an acute or chronic 
inflammation of the lungs, involving both the bronchial tubes and 
air-vesicles, and due to extension of inflammation from neighboring 
parts, aspiration or inhalation of irritants, or micro-organisms, — e.g., 
Diplococcus pneumoniae, staphylococci, streptococci, the diphtheria 
bacillus, and the bacillus of pneumonia, or it may follow as a sequel 
to the infectious fevers. The lung is larger, heavier, and firmer than 
normal, and in my experience the lower lobe of the right lung is most 
frequently affected. On section the surface is somewhat dark red 
in color, distinctly mottled, and may drip blood. On palpation irregu- 
lar nodular areas of gray hepatization can be felt, surrounded by 
crepitant tissue. The nodules, seldom larger than a hazel-nut, con- 
tain a central bronchiole surrounded by a grayish-red elevated area 
of consolidation and filled with tenacious purulent mucus which can 
be pressed out. Recent patches are red-brown in color, firm, smooth 
or finely granular, but later they are gray and soft. Minute hemor- 
rhages are common near the affected areas and on the pleural surfaces. 
The pleura is bluish in color and rough. Emphysema is seen on the' 
anterior and upper portions of the lung, especially within the inflamed 
areas. Fibroid changes seldom follow bronchopneumonia. Associ- 
ated with this variety of pneumonia may be found enlarged bronchial 
glands, a dilated right heart, gastritis, enteritis, congestion of the 
liver and kidneys, and rarely pericarditis or pulmonary thrombosis. 
Catarrhal pneumonia in itself, except in the very young or the very old, 
is rarely fatal. 

1 /;-. Amcr. Med. Assoc, April 30, 1904. p. 1133. 



152 POST-MORTEM EXAMINATIONS 

Chronic interstitial pneumonia may be due to acute inflammations 
(rare), tuberculosis, chronic pleurisy, chronic poisoning, or syphilis, 
and is usually unilateral. The chest on the affected side is sunken, 
deformed, and the shoulder depressed, the heart being drawn over 
to the affected side. The opposite lung is usually emphysematous. 
On opening the chest the affected part, more or less deeply pigmented, 
is seen to be almost airless, quite firm, and very resistant to the knife, 
lying back against the spine, and usually held by dense adhesions. 
On section grayish fibroid tissue of variable amount is found, which 
may be more or less dilated. The unaffected lung is much enlarged, 
occupying the greater portion of the mediastinum. The heart is 
hypertrophied and the blood-vessels may be atheromatous. Associ- 
ated lesions are tuberculosis or syphilis, a cavity of the apex, pul- 
monary aneurism, and amyloid disease of the viscera. 

Croupous {lobar) pneumonia, an infectious and contagious dis- 
ease, occurs especially in adult males, the Diplococcus pneumonice of 
Frankel being present in a large proportion of cases, though other 
organisms, such as the Aspergillus bronchialis, may be found. The 
organism, readily demonstrated in cover-glass preparations stained 
by Gram's method, is found in the bronchial secretions and in sections 
of the affected lung, in pairs, surrounded by a lanceolate capsule. 
Osier considers the mortality to be about one in four persons affected. 
The disease is divided into three distinct stages, — hyperemia, red 
hepatization, and gray hepatization, (a) In the stage of engorge- 
ment, which lasts about twenty-four hours, the lung is heavier, firmer, 
more solid, and redder than normal. It still crepitates, though not 
so distinctly as the healthy tissue. The cut section exudes a red, 
frothy serum and will partially float, (b) In red hepatization, which 
lasts from one to four days, the affected lobe or lobes are larger, 
heavier, and firmer than normal, and are of a deep-red color. They 
are airless, do not collapse on exposure to the atmosphere, and excised 
portions sink in water. The pleural surface of the lung is covered 
with a more or less extensive layer of fibrin, which forms a false 
membrane that contrasts markedly with the smooth shiny appearance 
of the unaffected portions of the lung. The surface may retain the 
impressions of the ribs. On section the lung is dry, reddish brown, 
and exceedingly friable. Careful inspection shows that the surface 
is distinctly granular, due to fibrinous plugs in the smaller bronchi 
and blood-vessels, which are lighter in color than the intensely red 



DISEASES OF THE LUNGS j,, 

tissue, and which can be scraped off with a knife together with a 
reddish-viscid serum. Such fibrinous masses may extend into the 
larger tubes and thus form perfect casts. The bronchi may contain 
a mucous secretion tinged with blood, or more rarely the tenacious 
mucus so characteristic of pneumonic sputum. The microscope re- 
veals in the alveolar meshes fibrinous threads, epithelial cells which 
have undergone hyaline and necrotic changes, leucocytes, red blood- 
cells, micro-organisms, etc. Sections taken from the central portion 
of the lung show more cellular elements, while those from the sur- 
face are richer in fibrin, showing that infection probably takes place 
from the bronchi. In this connection it is well to remember that there 
is a pneumonic form of plague and of several of the other infectious 
fevers. (c) In gray hepatization the color varies from a reddish 
brown to a grayish white. The surface is more moist, the exudate 
more turbid, the color grayish yellow or green. The granules are 
less distinct and the pulmonary tissue is still more friable. The exu- 
date is softened and the pneumococcus is usually no longer to be 
demonstrated. The cell-elements are disintegrated and prepared for 
absorption. Gray and red hepatization may coexist in the same lobe. 
Lesions in Other Organs. — (d) The bronchial glands are swollen, 
soft, and hemorrhagic. The overlying pleura is inflamed, with more 
or less extensive exudate, which may be serous, fibrinous, or, more 
rarely, purulent. The cavities of the right heart are often dis- 
tended with firm tenacious coagula. Pericarditis is not infrequent 
with pneumonia of the left side or double pneumonia, and is most 
common in children. Endocarditis is more common, and may be 
malignant and associated with meningitis, usually of the cortical 
variety. Myocarditis is rare. In many cases the spleen is enlarged. 
The kidneys and liver show cloudy swelling or acute parenchymatous 
changes. The hepatic veins are often engorged. 

Complications. — Otitis media, conjunctivitis, and arthritis are not 
unusual in children. Severe and often fatal toxaemia may develop 
with a comparatively slight lesion in the lung. Jaundice, croupous 
gastritis, croupous colitis, and peritonitis also occur. 

Terminations. — (a) Liquefaction, absorption, and resolution. 
(b) Suppuration. The lung is then an airless, firm, regular, gray 
or red mass. Abscesses should always be examined for tubercle 
bacilli, (c) Gangrene, (d) Fibroid changes or carnification. ( e) 
Lymphangeitis and perilymphangeitis may occur. 



154 



POST-MORTEM EXAMINATIONS 



TABLE SHOWING DIFFERENCES BETWEEN CROUPOUS AND 
CATARRHAL PNEUMONIA. 



Croupous Pneumonia. 
i. Whole lobe usually affected; hence 
the name lobar pneumonia. 

2. No areas of healthy lung tissue in 

affected lobe; other lobes healthy, 
but may be congested, especially 
those near the affected lobe. 

3. Lung weighs much more than nor- 

mal. An entire lobe may sink in 
water. 

4. Microscopic appearance varies ac- 

cording to stage. Much fibrin ; 
hence the name fibrinous pneumo- 
nia for this condition. 



5. An extensive fibrinous exudate on 

the pleura covering the affected 
area ("bread-and-butter" pleu- 
risy) ; hence the name pleuro- 
pneumonia for this affection. 

6. Pneumococcus usually found. 

7. Usually at base and posteriorly. 



8. Usually one-sided. 

9. On section the lung varies according 

to stage, the marbled appearance 
being especially striking in the 
third stage. Notice the fibrinous 
plugs. 

10. Sputum, so-called rusty sputum. 

n. Lung lesions of same age. 



Catarrhal Pneumonia. 

1. Lobules affected; hence the name 

lobular pneumonia. 

2. Irregular areas of lung tissue in va- 

rious stages of degeneration inter- 
mingled with normal lobules. 

3. Lung weighs but slightly more than 

normal. An entire lobe will float 
on water, though small portions 
may sink. 

4. Microscope reveals three zones : cen- 

tral, a small bronchus ; middle, a 
desquamative area containing many 
cells, but little or no fibrin; outer, 
a zone of congestion. Hence, the 
synonym, bronchopneumonia. 

5. Exudate slight, if present. 



6. Pneumococcus rarely found. 

7. Usually at the termination of the 

smaller bronchioles and anywhere 
in the lung. 

8. Usually on both sides and associated 

with other diseases. 

9. On section the lung is congested. 

Small angular irregular patches, 
the central portion being the oldest, 
are seen. 

10. Sputum more purulent. 

11. Diseased portion of the lung varies; 

some spots are old, some are new, 
the oldest being around the bron- 
chioles ; healthy tissue between 
affected areas. Caseous pneumo- 
nia, really a form of catarrhal 
pneumonia, is due to the action of a 
toxin, as from the tubercle bacilli. 
In phthisis there may be small 
areas of croupous pneumonia. 

12. Capillary bronchitis and catarrhal 

pneumonia are, pathologically, 
practically the same. 



DISEASES OF THE LUNGS !-- 

- — This fibroid condition of the lung, often 

ciated with tuberculosis, and produced by the inhalation of parti- 
cles of mineral or metallic substances, occurs in persons employed 
in such occupations as coal-mining, the manufacture of pottery, steel- 
grinding, stone-cutting, tobacco-sorting, etc. Various names are thus 
applied to it. depending upon the nature of the inspired dust, — 
anthracosis. siderosis. calcicosis. lithosis, silicosis, etc. Unless, as is 
frequently the case, emphysema coexists, the affected lungs are harder, 
firmer, often smaller than normal, and usually of a blue-black, yellow- 
ish, or buff color, affording a striking contrast to the lung of a child. 
Even when the inspired dust is white, the lungs are apt to be of 
a dark color, due to the carbon and the altered blood pigment. In 
advanced stages of anthracosis an ink-like juice may exude from the 
cut surface. In siderosis. caused by oxide of iron, the lung is of a 
reddish color. On section condensed portions of highly fibroid tissue 
are seen, with numerous raised points, which give it a coarse granular 
appearance. These raised points are small, thickened, fibroid bronchial 
tubes protruding above the surface. The deposits are found micro- 
scopically everywhere along the course of the lymphatics. The pleura 
is usually adherent, thickened, and pigmented. The signs of chronic 
bronchitis are present, though the mucous membrane of the bronchi 
remains unpigmented. The bronchial and peribronchial glands as 
well as the peribronchial lymph-nodules are frequently intensely pig- 
mented, and may be either soft or indurated. The liver and spleen 
may also be pigmented. True osseous formations, coral-like in shape, 
may be found in the lungs. 

Traumatism. — In accidents foreign bodies may enter the lungs. 
In one case reported 1 a woman fell from a ladder and a broom-handle 
passed through her chest from one axilla to the other : she recovered. 

Tumors. — The benign tumors of the lungs are fibroma, adenoma, 
ma. and chondroma. Hydatids are common in countries in- 
fested by that disease, and may attain considerable size. Dermoid 
cysts are found, but very rarely. Primary malignant growths are 
rare, involving one lung only, while secondary tumors are compara- 
tively common, affecting both lungs. Carcinoma may originate in 
the epithelium of the alveoli, the bronchi, or the mucous glands. 
ndary cancer is more frequent in women than in men and may 

1 Franke. Arch. f. klin. Chirurgic, 1903. vol. lxxi, no. 2. p. - 



156 POST-MORTEM EXAMINATIONS 

be scirrhous, encephaloid, epitheliomatous, or colloid. Endothelioma 
starts from the lymphatic apparatus. Primary spindle-celled sarcoma 
and melanosareoma are found, which often extend to the liver. The 
tracheal or bronchial glands are sometimes the seat of metastatic 
growths. In malignant diseases of the lungs, pleurisy, generally of 
a hemorrhagic type, is commonly present. 

Pleura. — Empyema (Pyothorax). — Suppuration in the pleural 
cavity is usually accompanied by the presence of air, and is due to 
pleurisy, extension of inflammation from neighboring organs, trauma, 
and micro-organisms, especially the tubercle bacillus, the diplococcus 
of pneumonia, and the streptococcus and staphylococcus pyogenes. 
The pleurae are much thickened ; their surfaces are irregular and cov- 
ered with a yellowish-green exudate of varying thickness. There 
may be evidences of more or less extensive hemorrhage, also erosions, 
fistula?, or perforations. In severe cases there may even be gangrene. 
The pus separates into two layers, — a clear greenish-yellow serum 
above, a thick cream-like pus below. It has a heavy sweet odor, and 
is rarely fetid unless gangrene supervenes. A sterile culture on ordi- 
nary media suggests tuberculosis. 

New Growths. — The benign tumors of the pleura are fibroma, 
osteoma, chondroma, and lipoma. Endothelioma originating from the 
lymphatics may cause a diffuse thickening of the pleura. Teratoma 
has been reported, in one case attached to the tenth rib, aorta, and vena 
cava. Carcinoma and sarcoma occur, usually as secondary deposits. 
Hydatid cysts are very rare in this country. Tuberculosis of the pleura 
is described elsewhere. 

Pneumothorax. — This is the presence of air in the pleural cavity, 
and may be due to traumatism, tuberculosis of the lung rupturing into 
the pleura, other infectious granulomata, and malignant growths. 
The thorax is usually distended and the intercostal spaces may be 
obliterated. The introduction of a trocar allows the escape of the air. 
Unless pneumothorax kills suddenly, it is always accompanied by 
a pleurisy, generally of a purulent variety. The pericardium and 
heart are pushed or drawn to the opposite side. The lung is usually 
compressed and carnified and may be adherent to the chest wall at 
the apex, this site being frequently the seat of caseous nodules or 
cavities. Localized pneumothorax is probably often overlooked at 
the postmortem. 

Hydrothorax. — This is part of a general dropsy, and is usually 



DISEASES OF THE LUNGS j^y 

due to chronic valvular disease, chronic Bright's disease, cirrhosis of 
the liver, cachexia, or pressure on the azygos veins. As a rule, it is 
bilateral, although not equal in extent in the two sides. The lungs 
are compressed and the pericardium and heart pushed upward. 

Hemothorax. — This is generally clue to trauma, sometimes to can- 
cer of the lung or pleura, also found with tuberculosis, purpura, scurvy, 
leukaemia, cirrhosis of the liver, and granular kidneys. 

Chylothorax. — An effusion of chylous fluid is rare, and is due 
to traumatic rupture or obstruction to the thoracic duct. 

Pleurisy. — Inflammation of the pleura may be acute or chronic. 
It is due to exposure to cold and wet, traumatism, extension of in- 
flammation from neighboring organs, pyogenic micro-organisms, 
many infectious fevers, infectious granulomata, or malignant tumors. 
Acute pleurisy is classified by the character of its exudate into serous, 
serofibrinous, fibrinous, purulent, and hemorrhagic. In all, the serous 
membrane is at first red, sticky, and lustreless, and the vessels are 
dilated; later it becomes pale, thick, and rough. The pleural cavity 
may contain an inflammatory exudate, varying in amount from a few 
cubic centimetres to one or more litres, resembling that seen in other 
serous cavities. The serofibrinous exudate contains more fibrin but 
less fluid. Coagula may be found in situ. The characteristic of the 
fibrinous exudate is the so-called " bread-and-butter" appearance of 
the pleura. The deposit varies in thickness from a millimetre to a 
centimetre or more. Purulent pleurisy may follow the acute form or 
may be primary. It is frequently associated with tuberculosis. The 
serous membranes are covered with a creamy exudate and the cavity 
contains from a few cubic centimetres to a litre or more of greenish- 
yellow, offensive pus. In the tuberculous exudate Ravaut and Widal 
have found a predominance of lymphocytes, while other effusions con- 
tain polymorphonuclear neutrophiles. Hemorrhagic pleurisy may be 
due to asthenic conditions, as tuberculosis and cancer, or may occur 
in perfectly healthy individuals, from wounds to the lungs during 
aspiration by the mixing of any fluid present with blood. The pleural 
cavity contains blood, usually fluid and varying considerably in den- 
sity. The serous membranes are generally inflamed and stained with 
blood-coloring matter. Chronic pleurisy with effusion may persisl 
for months without undergoing any alteration in its character. The 
post-mortem appearances are very similar to those of an acute pleu- 
risy. Chronic dry pleurisy, resulting from the partial absorption of 



158 POST-MORTEM EXAMINATIONS 

a pleuritic exudate and the organization of the remainder, occurs 
usually at the base, causing marked flattening of the chest. Small 
pockets of fluid are often found and it is frequently impossible to 
separate the layers of pleura. The lung is compressed, airless, and 
fibroid. Primitive dry pleurisy may be limited or universal, unilateral 
or bilateral, and may be accompanied by- a similar condition of the 
pericardium and peritoneum. The layers of the pleura are firmly 
adherent to one another and, especially about the lower lobe, are much 
thickened. In tuberculous cases reddish-gray fibroid masses and small 
tubercles are present between the layers, sometimes infiltrated with 
serum. The bronchi may present marked dilatations and the pul- 
monary tissue be more or less sclerosed. In diaphragmatic, encysted, 
and interlobar pleurisy the morbid anatomy is similar. 



CHAPTER X 

CRITICAL EXAMINATION OF THE ORGANS OF THE ABDOMINAL CAVITY 

The Omentum, Mesenteries, and Peritoneum. — The super- 
ficial examination of the peritoneum having been made during the 
general inspection of the abdominal cavity, any thick regions are now 
felt with the index-finger and thumb and, should anything abnormal 
be found, such areas are at once incised and critically studied. A 
regular order should be chosen for the study of the peritoneum, say 
from above downward, so that nothing of importance shall escape 
the attention of the one making the autopsy. 

The peritoneum covering the diaphragm may become inflamed 
as part of a general peritonitis, or show the presence of aberrant 
pulmonary tissue, cysts, filaria, actinomycosis, lipomata, fibromata, en- 
dothelioma, and secondary tumors. The Distoma hepaticum has been 
found embedded in the peritoneum of this region. Subdiaphragmatic 
(subphrenic) abscesses are not uncommon, especially on the right side, 
and may rupture into the pleural cavity or remain localized. In 
Korte's 1 sixty cases, which were operated on by himself, infection 
was found to originate most frequently from the vermiform appendix. 
Among the other causes giving rise to this condition may be men- 
tioned : (a) perforation of a gastric or duodenal ulcer; (b) abscess 
of the liver and pancreas; and (c) diseases of the lower ribs, pleura, 
and mediastinum. Mandl has tabulated 179 cases from the literature 
on this subject. 

A volvulus or hernial opening of the omentum may require its 
removal; although, as a rule, it is best to make examination of any 
abnormalities or pathologic lesions that appear and afterwards to 
remove the omentum along with the transverse colon. In thin sub- 
jects the separation of the omentum into its four layers, one anterior 
and three posterior, forms a striking picture, especially if studded with 
recent miliary tubercles or the wild strawberry-like nodules of a sar- 
coma. The hremolymph-nodes in man and in sheep have recently been 
studied with special care by Warthin. He thinks that they have to 
do with the destruction of the red blood-corpuscles. 



1 Gruneisex, Archiv f. klin. Chirurgie, 1903, vol. lxx, p. 1. 



159 



160 POST-MORTEM EXAMINATIONS 

The mesentery may be shortened by contraction, as by granulation 
of the tissue, or lengthened, as by traction upon the bowel in a strangu- 
lated hernia. Congenital redundancy of the sigmoid flexure may later 
cause chronic obstipation and hypertrophy of the colon. Hemorrhage 
may take place into the mesentery in phosphorus poisoning and acute 
yellow atrophy of the liver. The glands are red and swollen in enter- 
itis, especially in typhoid fever, where they may be very numerous 
and break down. They afford a favorable spot from which to secure 
cultures for the different varieties of colon and typhoid bacilli. When 
the glands become tuberculous, they often caseate and may reach a 
large size. In the tabes mesenterica of children they are usually 
enlarged, even in non-tuberculous cases. All statistics bearing upon 
tuberculous infection of these glands are extremely useful at the 
present time, in order to place upon a sound scientific basis the rela- 
tion of tuberculous milk to infant mortality. One also finds here 
enlarged glands in leukaemia and Hodgkin's disease. By the stop- 
ping up of the blood-vessels, the mesentery may become dark in color 
and cause many feet of the small intestine to become gangrenous. It 
may be wholly converted into a mass of fat. Search should be made 
for calcified tubercles, tumors, parasites, chylocysts, etc. Hemorrhagic 
infarcts are sometimes seen. A recent postmortem of infiltrated blood 
into the mesentery from a ruptured aneurism of the superior mesen- 
teric artery showed the distribution of the blood to the mesenteries 
of the jejunum, ileum, caecum, vermiform appendix, colons, and rec- 
tum. It is well to remember that the duodenum is not supplied with a 
mesentery. 

Cancer of the peritoneum is found especially in the female sex 
after the change of life, and is most often secondary to cancer of the 
stomach or ovaries. It is spoken of as " miliary carcinosis" because 
the nodules are small, spherical, and diffuse. The serous membranes 
are pale, thickened, with marked fibrinous deposits, which form adhe- 
sions to neighboring viscera; the omentum is indurated, and forms 
a mass transversely across the abdomen; the bowels are often firmly 
matted together. Ascites is usually found ; the amount of fluid pres- 
ent may be several pints or only a few ounces. In some cases of col- 
loid cancer the masses are of large size. 

Among the micro-organisms capable of demonstration in acute 
general peritonitis may be mentioned the Streptococcus pyogenes, Ba- 
cillus colt communis, Staphylococcus aureus, Streptococcus lanceolatus, 



EXAMINATION OF THE ABDOMINAL ORGANS ^j 

Bacillus proteuSj Bacillus pyocyaneus, and, more rarely, the gono- 
coccus (in the female) and the anthrax and typhoid bacilli. The cause 
of the peritonitis is usually from a perforation of the bowel. It may be : 
(a) Serous, (b) Serofibrinous, (c) Fibrinous, (rf) Purulent, (c) 
Putrid. (/■*) Hemorrhagic, (g) Ulcerative. In acute general peri- 
tonitis the peritoneum has lost its lustre, is opaque, and is covered with 
an exudate varying with the type of the disease. The intestinal coils 
are distended and glued together with lymph. They are more or less 
displaced and compressed, and their walls are easily torn. The serous 
membrane may easily be separated from the muscular coat. In peri- 
tonitis due to perforation, the peritoneum and its contents are dis- 
colored by the fasces, while the peritoneal cavity contains gas, which 
escapes with a hissing noise when an opening is first made in the ab- 
dominal cavity. 

Causes of chronic peritonitis: (a) Follows acute, (b) Tuber- 
culosis, (c) Extension of inflammation from the abdominal or- 
gans, (d) Cancer. Classification. — (a) Local adhesive. (&) Dif- 
fuse adhesive. (c) Proliferative. (d) Hemorrhagic, (i) Local- 
ized peritonitis occurs about the spleen, diaphragm, liver, intestines, 
mesentery, and pelvic organs. Bands of connective tissue more or 
less firmly organized bind the various organs together, producing 
marked alterations in the appearance and position of the parts. The 
peritoneum is thickened and puckered. (2) Diffuse adhesive perito- 
nitis follows acute inflammation, either of a simple or tuberculous 
nature. The abdominal cavity is often obliterated; the intestinal 
coils are firmly matted together by the plastic exudate, which eventu- 
ally becomes converted into bands of fibrous tissue. The spleen and 
liver are usually involved in the adhesions. In this variety I have seen 
a central cavity produced which contained the entrance and exit of 
several coils of the small intestines, the functions of life having ap- 
parently been carried on for a long while. (3) In the proliferative 
form there is great thickening of the peritoneum, which is opaque and 
white in color. The omentum is usually rolled into a thick mass be- 
tween the stomach and the colon. The liver and spleen are the sub- 
jects of a chronic capsular inflammation; both are usually smaller 
in size, with thickened, wrinkled capsules. There arc seldom many 
adhesions, and serous effusion may be present in the abdominal cavity. 
The intestinal wall is greatly thickened and the mucous membrane of 
the ileum is thrown into folds. Nodular thickenings may be present 



[62 POST-MORTEM EXAMINATIONS 

and be mistaken for tubercles. (4) The hemorrhagic form occurs 
particularly in cancerous and tuberculous conditions. Layers of new 
connective tissue form on the surface of the peritoneum; they con- 
tain large blood-vessels, from which the bleeding occurs. It is com- 
monly a circumscribed process. Orth compares it to chronic internal 
heme >rrhagic pachymeningitis. 

In order to obtain more room for the examination of the abdomi- 
nal cavity and a more favorable opportunity for the subsequent in- 
spection of the gall-bladder, biliary ducts, and portal vessels, the 
attachments of the diaphragm to the ribs on the right side may now 
be severed with the knife and the liver rolled over into the thoracic 
cavity of this side. 

The Spleen. — The spleen varies greatly in size and weight, even 
during health and in the same individual at different times. Its nor- 
mal weight is about five ounces and the measurements are five by one 
and one-fourth inches. I have removed a spleen which weighed only 
one hundred and eighty-six and one-half grains (senile atrophy) and 
another weighing over seven pounds (malarial enlargement.) En- 
largement of the spleen is also seen in sepsis, typhus, syphilis, etc. Re- 
member that the spleen affords a favorable opportunity for the study of 
micro-organisms, especially of the typhoid and colon groups. The 
spleen may now be removed from the abdominal cavity, although some 
pathologists recommend its excision later in connection with the pan- 
creas. It is easily found by passing the hand along the left under 
surface of the diaphragm from the eighth to the eleventh rib, well 
towards the side and beneath the cardiac end of the stomach. Usually 
but little force is necessary to bring it into view, with the gastrosplenic 
omentum and splenic artery and vein still intact. These parts are then 
cut or torn with a sort of twisting movement. In some cases the 
spleen is so soft that lacerations may be made in its substance by the 
fingers. These should not be mistaken for traumatic rupture of the 
organ, as from a kick, or for the rupture that sometimes, although 
rarely, results from disease. Occasionally the spleen is absent, its 
place being taken by a large number of supernumerary spleens or by 
an increase in the lymph-nodes of the peritoneum. The spleen may 
be found attached to the surrounding parts, or a wandering spleen 
may even be found in the left inguinal region. Before detaching 
it, examine the course of the splenic artery for aneurisms, super- 
numerary spleens, enlarged glands, etc. When this has been done, 



EXAMINATION OF THE ABDOMINAL ORGANS ^ 

the artery may be divided and the organ removed from the body. 
Notice whether or not the capsule is normal or thickened ; it should 
be thin, smooth, and transparent. At times the capsule, from which 
trabecule extend into its pulp, appears as if melted tallow had been 
poured over the surface and allowed to dry. 

Xow lay the spleen, resting upon the hilum (posterior surface), 
on the table, fix it with the left fingers, and with one stroke incise it 
in its longest diameter. The spleen being turned, transverse incisions 
to those made upon the anterior surface may be made for further 
investigation. The color of the normal spleen is dark red, somewhat 
darker and of a bluish tinge in children ; it may be brownish, from 
the presence of hemosiderin ; or yellow, as in jaundice (or in the 
new-born, due to bilirubin crystals) ; or streaked with blue, owing to 
the presence of melanin. Coal-dust may be found in the spleen, 
having probably entered the circulation through the peribronchial 
glands. Hyperplasia of the fibrous stroma in cases of chronic en- 
largement of the organ, as in malaria and leukaemia, may give to the 
spleen a grayish tinge. 

The structure of the splenic tissue may then be examined, and 
the changes in the splenic pulp, the Malpighian bodies, and the 
connective-tissue trabecular noted. The elastic tissue of the spleen 
may be destroyed, as in tuberculosis, or hypertrophied around the 
capillaries, as in leukaemia. 1 A disturbance of the local circulation 
may lead to various changes. Oligemia is marked by the light-red 
or grayish-red color of the spleen, with wrinkling of the capsule and 
prominence of the trabecule. Obstruction to the portal circulation 
causes congestion. Hyperemia due to congestion is characterized by 
an enlarged, hard, dark-red splenic pulp, with smooth surface on sec- 
tion and thickening of the capsule, trabecule, and vessel-walls. In- 
farcts of the spleen are common, and are usually wedge-shaped, with 
the apex towards the hilum. They van' in size from that of a pea 
to that of a cherry, and may at times include half of the spleen ; they 
may become infected. Anemic infarcts are of a cloudy-yellow color, 
while the less common hemorrhagic infarcts are very dark red. and 
later become yellowish red, and even whitish yellow as the coloring 
matter of the blood disappears. Acute splenitis, resulting in the for- 
mation of pus, is not frequent. An acute proliferative splenitis, the 

'Fischer. Virchovfs Archiv, 1904. vol. clxxv, no. l, p 



K) 4 POST-MORTEM EXAMINATIONS 

cause of the so-called splenic tumor, is characterized by enlargement 
of the spleen, with the capsule markedly on the stretch, and the pulp, 
on section, being of a vivid red, at first darkish and later somewhat 
lighter. The pulp is soft and exudes on section, so as to conceal the 
Malpighian bodies. Fibrous, productive, or chronic inflammation of 
the spleen causes the chronic splenic tumor, recognized by the large 
size of the organ, which is hard, of a light or dark brownish hue, with 
thickened trabecular, that may appear as streaks through the splenic 
substance. A leuksemic spleen with its umbilicated nodules is hard and 
of a reddish-gray color, sometimes weighing twenty pounds. Miliary 
tubercles, with caseation, and other tumors of the spleen occur. In 
the colored race miliary tubercles at times do not undergo caseation 
and may attain the largest size of any developing in the body. I have 
not infrequently seen them as large as wild cherries. The arteries in 
the splenic pulp rarely show macroscopic atheroma, although the tis- 
sue of the spleen may be infiltrated with the salts of lime. The most 
important of all the forms of retrocessive disturbances of nutrition 
of the spleen is amyloid degeneration. In this disease the spleen is 
firm and inelastic, so that the pressure of the finger leaves a decided 
mark. Amyloid degeneration of the pulp is characterized by the 
smooth, shining, almost transparent appearance of the cut surface, 
while the so-called sago spleen — the amyloid degeneration of the Mal- 
pighian bodies — is recognized by the enlargement of the lymph-nod- 
ules, which on section appear somewhat transparent and scattered over 
the cut surface. The amyloid reaction would be more frequently 
demonstrated if Lugol's solution were applied as a routine practice. 
A small piece of the spleen should also be tested for iron with ammo- 
nium sulphohydrate. The Pentastomum denticulatum and echino- 
coccus cysts of the spleen are sometimes found, as well as multiple 
angiomata, cancer, and sarcoma, the latter occurring, in rare instances, 
primarily in this organ. On healing, gummata leave behind stellate 
scars of varying size. 

The Intestines, except the Duodenum. — When the exudation 
in the peritoneal cavity is fibrinopurulent and has a fetid odor, its 
source should be sought in a perforation of the intestine, although it 
may have originated elsewhere, as from the uterus or adnexa. If the 
peritoneal fluid suggest perforation, the gut may be examined under 
water, as pressure on the intestine will then cause bubbles of gas to 
appear. The site of perforation is usually marked by an area of 



EXAMINATION OF THE ABDOMINAL ORGANS 165 

fibrinous exudation, which may be so dense as to occlude the open- 
ing: or there may be several perforations, as in a case of typhoid 
fever. In duodenal ulcer the contents will be stained with bile. Ery- 
sipelas and poisoning- by arsenic should be remembered as occasional, 
though rare, causes of intestinal ulcer. The exterior of the entire 
intestinal tract should be critically inspected, starting from below and 
going upward, and any adhesions should be very gently broken down, 
care being taken not to make an artificial opening in the bowel, — an 
accident quite apt to occur in certain diseased conditions. When, how- 
ever, the intestines are extensively agglutinated, as in appendicitis, 
tuberculous peritonitis, etc., the parts may often be better studied by 
first carefully noting their relations and then removing them en masse. 
Observe whether there be distention or contraction of the bowels. 
Distention is marked in cases of stenosis or strangulated hernia, and 
when a large amount of fasces is contained within the intestines. Con- 
traction is noted in enteritis and after starvation. Localized constric- 
tions may be due to bands of peritoneal adhesions. A Meckel's diver- 
ticulum should not be overlooked, and its omphalomesenteric attachment 
going to the umbilicus should be searched for. The duct sometimes 
remains patulous until puberty, or even later. The lymph-follicles may 
be injected, and are noticeable as irregular whitish 
lines which, when pricked, exude a drop of milky 
fluid, — chyle. 

A proper examination of the intestines can be 
made only after they have been removed from the 
body. For this purpose the intestine is doubly 
ligated in three places, — viz., ( 1 ) at the end of 
the duodenum and the commencement of the jeju- 
num; (2) in the ileum, several feet above the 
ileocecal valve; and (3) at the end of the sigmoid 
flexure and the commencement of the rectum. The 
method of doing this is as follows. A loop of 
string: is carried by the nail of the index-finger F,G - -Method oi 

° J # passing the String through 

(Fig. 90) through an Opening in the mesentery an opening in the mesentery 

made with an instrument or the fingers and the in- >' nvl " us 
testine is ligated. A second ligature, far enough from the firsl t<> allow 
of the gut being divided between them later, is then applied (Fig. 91, 
facing p. ill J. Care should be taken that the ligatures 1>e tightly held 
so as to prevent slipping, thus affording an opportunity for the escape <>f 




]()0 POST-MORTEM EXAMINATIONS 

fecal matter. The large intestine is then cut between the ligatures, and 
its proximal extremity grasped and the mesentery severed by a sawing 
or fiddle-bow movement close to its intestinal attachment along the 
whole extent of the colon, until the ligatured spot in the ileum is 
reached, when the small intestine is incised between the ligatures. This 
portion is then removed to the sink or bucket preparatory to being 
cleansed (Fig. 92), and the remainder of the ileum and the jejunum 
are removed, as seen in Fig. 93, and also placed in the sink or bucket. 
The intestines are opened either by pushing them into the open 
blades of the scissors or, better, by thrusting the enterotome or scis- 
sors through the bowels along the line of the mesenteric attachment 
(Fig. 94). Meckel's diverticula, like Peyer's patches, usually occur 
opposite the mesenteric attachment and, therefore, on the free anterior 
border of the ileum ; hence the reason for opening the bowel at its 
mesenteric attachment. The ileocaecal opening is guarded by the two 
valves of Bauhin, the superior one normally covering the inferior. 
Each valve is to be examined on its iliac and caecal surface. The 
ileocaecal cut is to be made between the two valves ; this is readily done 
by dissecting the ileum down to the valves, and then, as is usual, 
pushing the enterotome through the opening in the direction in which 
the chyle passes, — i.e., towards the caecum and between the two. valves. 
The appendix is opened opposite its mesenteric attachment, contrary 
to the rule in the case of the intestines. The situation of the valve 
of Gerlach is very variable. If a competent dead-house assistant is at 
hand, the opening of the bowel may be intrusted to him, as it saves 
the operator's time and prevents his hands from becoming impreg- 
nated with the disagreeable fetid odor of the gut. The assistant is 
instructed to call attention at once to any abnormalities observed, and 
opens all the intestinal tract except the ileocaecal valve and the vermi- 
form appendix. These are to be incised and examined by the patholo- 
gist himself. The small and large intestines, after being freed of their 
contents, should be measured and weighed apart, the ileocaecal valve 
counting with the large intestine. After washing, the entire bowel is 
arranged, mucous surface upward, upon the post-mortem table, so 
that the pathologist may at a glance examine the intestines throughout 
their entire extent. In cases in which haste is a matter of importance, 
the intestines need not be removed from the body, but at the end of 
the autopsy the region of the ileocaecal valve is opened as well as the 
sigmoid and rectum, and, if no lesions are discovered here, the remain- 



F I jj r 

* a* a 






EXAMINATION OF THE ABDOMINAL ORGANS jfy 

ing portion remains unopened, unless palpation or inspection in the 
preliminary examination of the abdominal cavity has led one to sus- 
pect a lesion in other situations. If a spigot is at hand, the open end 
of the intestine may be drawn over it. and the water allowed to run 
through until clean. Passage of water from a stop-cock to cleanse 
the intestines is not. however, always a proper procedure, as it may 
injure the mucous membrane, rupture a Peyer's patch in typhoid fever, 
loosen some of the intestinal contents, change their consistence by ad- 
mixture with water, etc. The bucket method of opening and cleansing 
the intestines — a very useful one in private cases — is illustrated in 
Fig. 92. In warm weather these viscera are particularly liable to 
undergo rapid decomposition after exposure to the air. 

The color of the normal mucous membrane of the intestine is light 
gray, varying according to the contents of the bowel and the amount 
of blood present. Congestion of the small capillaries causes a general 
redness, while injection of the larger vessels produces red streaks;' 
the two conditions may occur together. The greater the distention 
of the bowel the more pale is the grayish shade of the mucous sur- 
face, and if the contents of the gut are bloody, the walls are dark red. 
This diffused color is to be distinguished from the redness due to 
hyperemia, occurring in inflammations, congestions, etc., by the' 
marked injection of the capillary blood-vessels which is seen in the 
latter case. Even the vessels of the submucosa are observed to be 
overfilled. Thickening of the walls as well as partial overgrowth of 
the mucous membrane, often in the form of small polyps, may be ob- 
served in many of the chronic inflammations of the intestines. En- 
larged villi, individually made out with the naked eye, may be noted 
in some cases of inflammation. (Orth.) 

The following tabulation will be found of use in distinguishing 
typhoid and tuberculous ulcers. 

DIFFERENCES BETWEEN TYPHOID AND TUBERCULOUS ULCERS. 1 
Typhoid Ulcers. Tuberculous Ulcers. 

1. Direction often longitudinal, in- 1. Direction transverse (frequently). 
volving the Peyer's patches, which This distinction is not so char- 

are larger in size; actual amount acteristic as is sometimes held. 

of surface involved greater. The ulcers are smaller and may 

be very numerous. 

1 After Woodhead, Practical Pathology, 3d edition, p. 455. 



1 68 



POST-MORTEM EXAMINATIONS 



DIFFERENCES BETWEEN TYPHOID AND TUBERCULOUS ULCERS. 



Typhoid Ulcers. 

Edges undermined, ragged, and can 
be floated out on water; thin, 
vascular, and composed of mu- 
cosa and submucosa; red. 



3. Floor smooth and vascular. 



4. Peritoneal surface unaltered, except 

that it may be inflamed. No 
thickening and no gray or yellow 
patches. 

5. Mesentery unaltered ; glands en- 

larged, vascular, pink, and soft- 
ened. 



6. Perforation more common both by 

separation of slough and by direct 
extension of the ulcerative pro- 
cess. Small opening by which the 
faeces may escape. Peritonitis. 
Hemorrhage may occur during 
either of these processes. 

7. Microscopically: A specific inflam- 

mation affecting the adenoid tis- 
sue ; blood-vessels distended, and 
increased vascularity of the mu- 
cosa and the submucosa. Dense 
masses of small round cells — lym- 
phoid cells and leucocytes — with 
some large multinucleated cells, 
the latter of which are derived 
directly from endothelioid cells. 
A line of demarcation is formed 
and abscess results, beginning in 
the solitary glands and other lym- 
phoid tissue of the mucosa and 
submucosa. Widal test positive. 

8. Extension takes place laterally or in 

depth. 

9. Heals by granulation, the thin edges 

falling on to and uniting with the 
granulating floor of the ulcer. 



Tuberculous Ulcers. 

2. Edges not undermined ; thick, promi- 

nent, nodulated, terraced, or 
sloping; pale or red; composed 
of tissue infiltrated with tubercu- 
lous nodules. 

3. Floor nodular, irregular, thickened, 

vascular, with pale or yellow 
points or areas. 

4. Peritoneum thickened ; small yellow 

or gray points in the floor of the 
ulcer running along the lines of 
the lymphatics. 

5. Mesentery thickened at its attach- 

ment to the bowel; glands en- 
larged, firm and gelatinous on 
section, or caseous. 

6. Perforation, peritonitis, and hemor- 

rhage are all rare. 



Microscopically: A specific inflam- 
matory affection of the adenoid 
tissue and the mucous membrane, 
ending in caseation and connec- 
tive-tissue formation; vascularity 
of the mucosa and submucosa; 
increase of the connective-tissue 
cells and lymphoid cells; tubular 
nodules, typical or caseating. It 
begins in the mucous membrane, 
and, like the typhoid lesion, is 
due to direct contagion or infec- 
tion. Widal test negative. 



8. Extension usually takes places later- 
ally. 



9. Very rarely heals. 



EXAMINATION OF THE ABDOMINAL ORGANS 



169 



DIFFERENCES BETWEEN TYPHOID AND TUBERCULOUS ULCERS. 
Typhoid L t lcers. Tuberculous Ulcers. 

10. Leaves a smooth, often depressed, 10. Leaves a puckered cicatrix in which 

pale, anaemic, or pigmented cica- are gray or white nodules; often 

trix, covered by a layer of epithe- breaks out afresh. 

Hum, but no gland tissue. Sel- 
dom breaks out afresh, relapses 
being due to the affection of ade- 
noid patches previously little 
damaged. 

11. Presence of typhoid bacilli, which are II. Presence of tubercle bacilli easily 

also found in the enlarged mesen- demonstrated, 

teric glands and in the spleen. 

12. Spleen enlarged and soft. 12. Evidence of tuberculosis elsewhere, 

especially in the lungs. 

Cases of paratyphoid fever explain the occasional failure of the 
Widal test. A most careful study of all typhoid cases should, there- 
fore, be made where the Widal reaction was not obtainable during 
life. The anatomic findings in the cases of paratyphoid fever 1 which 
have come to autopsy are those of septicaemia with splenic swelling 
and at times ulcers which resemble those of dysentery and do not 
affect Peyer's patches. 

Whether during life a rectal enema may, by reversed peristalsis, 
be carried to the stomach and then vomited is an interesting but de- 
bated question which I believe should be answered in the affirmative. 
It is very difficult by pressure to force liquid past the ileocecal valve, 
but in relaxed conditions, as in cholera, this is perfectly possible. The 
problem is interesting as bearing on the possibility of a gastrocolic 
fistula and reversed agonal invaginations. 

Mayo Robson 2 has reported a case of peptic ulcer which devel- 
oped in the jejunum forty months after the performance of a gastro- 
enterostomy. 

An abundance of fasces in the large intestine indicates constipation, 
which occurs in an extreme form in partakers of opium, where one 
may find scybalous masses lying in pouches in the transverse colon as 
hard and dry as if they had been retained there for many weeks or 

1 Wells and Scott, Journal of Infectious Diseases, vol. i, January, [904, p. 72. 

2 Annals of Surgery, August, 1904, p. 186. 



[70 POST-MORTEM EXAMINATIONS 

even months. A similar condition is sometimes found in old persons 
subject to chronic constipation; the masses even become encrusted 
with salts oi lime. Distention of the small intestine shows that con- 
siderable Food was recently taken. When the lacteals are well dilated, 
some three and a half hours have elapsed since the taking of the food 
which has reached this portion of the intestine. Pavlof finds that 
psychical secretion of the intestinal juices varies markedly according 
to the character of the food ingested. When the faeces are light in 
color, an absence of bile is shown; when dark or light red, blood is 
probably present, although it must be remembered that medicines, such 
as hematoxylin, may give a similar appearance. When dark or black, 
the presence of iron or bismuth may be suspected; if yellow, the pos- 
sible administration of rhubarb should be considered. 

Gall-stones and worms may be found anywhere in the intestinal 
tract, but most frequently above the ileocecal valve and in the lower 
rectum. In one of my cases I found, not far apart, two Tcunice medio- 
cancllatcr, their heads being firmly attached to the mucous membrane 
beneath folds of the valvulse conniventes at the end of the duode- 
num. A specimen of ascarides in the Wistar and Horner museum of 
Philadelphia shows where one of them had penetrated the bile-ducts. 
As these worms try to escape from the body after death, this may be 
an instance of post-mortem penetration. Seat-worms are found in 
the lower rectum. Packard removed post mortem, at the Pennsylvania 
Hospital, a specimen of Tcunia nana. The Ankylostoma americana 
has been seen several times in Philadelphia. Loeb and Smith have 
recently pointed out the presence of a substance inhibiting the coagu- 
lation of the blood in the Ankylostoma canimim. Of course any of 
the varieties of intestinal worms seen in man may be found here, but 
it is surprising how few cases are described in post-mortem notes of 
our hospitals. The foulest odors arise in icterus and dysentery, while 
in cholera the odor may be hardly perceptible. True intestinal sand 
may be found and is largely composed of the phosphate and carbonate 
of calcium. It is most often caused by a pure milk diet or one of milk 
and lime-water. False sand, composed of biliary and fecal concretions, 
is more common, being seen especially in the vermiform appendix. 
Salol, when taken medicinally, may cause the formation of crystalline 
enteroliths. Tn a case of Brossard, 1 one of a number of calculi weighed 

1 Bull. gen. de therap., 1897, vol. exxvii, p. 363. 



EXAMINATION OF THE ABDOMINAL ORGANS ij L 

two grammes. The tumors of the intestines are myoma, fibroma, 
polyps, lipoma, adenoma, carcinoma, and sarcoma, the latter variety 
being of rare occurrence. (Plate IV.) 

In hemorrhage of the bowel the bleeding may be localized or dif- 
fused. In the former variety petechial spots or ecchvmoses are found 
on the mucous membrane. The mucous membrane surrounding the 
hemorrhages may be normal in appearance or show the results of active 
or passive congestion. In diffuse hemorrhages the blood is free in the 
bowel or may be extravasated into the mucous membrane. In the 
former case it is brownish black or black in color and usually semi- 
liquid or tarry. In the latter case the extravasated blood is in slate- 
colored or black patches. 

The average length of the appendix is about three inches, although 
it may measure as much as six. There is a mesentery often reaching 
to the tip and containing fatty deposits. The appendix may be absent. 
Its usual direction is towards the brim of the pelvis, but it may point 
in any direction. Appendicitis is most common in males and in early 
adult life, and is favored by fecal concretions, but rarely by foreign 
bodies. Among the articles found in the appendix have been pins, 
fecal masses, calculi, worms, gall-stones, fish-bones, tip of a ther- 
mometer bulb, seeds and fruit-stones, as of grapes, cherries, prunes, 
etc. The theory has recently been advanced that influenza and syphilis 
are common causes of many cases of appendicitis. Metschnikoff thinks 
that the condition is often associated with worms of various sorts. 
The principal micro-organisms are the Bacillus coli (most common), 
Streptococcus pyogenes, Staphylococcus pyogenes, B. tuberculosis, B. 
typhosus, B. inHuenscB, Proteus vulgaris, B. pyocyancus, Actinomyces, 
B. pseud otetanus, Micrococcus tetra genus, and B. ccdeniatous maligni. 
A mixed infection is usually present, upon an average three species 
being found in each case. The normal appendix is never sterile, while 
the diseased organ is sterile in ten per cent, of cases. (Lanz and Tavel.) 
Acute forms: catarrhal, follicular, suppurative, and gangrenous. Of 
the chronic: catarrhal, obliterative, and chronic infective. In acute 
forms the appendix is reddish brown, black, or greenish yellow in color. 
The mucous membrane is swollen, reddened, and presents hypertro- 
phied follicles, ulcerations, or a false membrane. The whole appendix 
is thickened, the serous membrane red and lustreless. In the suppura- 
tive form the abscess may be small and limited to the appendix : when 
large the pus frequently in wades the peritoneal cavity, the sac being 



]-j POST-MORTEM EXAMINATIONS 

formed by peritoneum, fibrinous exudate, and fibrous adhesions. It 
should be remembered that in cases of appendicitis abscess formation 
may start outside of the appendix and there be no perforation. In 
severe cases following ulcerative or obliterative conditions the abscess- 
cavity may contain the whole or a portion of the appendix which has 
been sloughed off. The abscess-cavity may become limited and remain 
so and be subsequently absorbed, or it may later open into the general 
peritoneal cavity. Rarely it breaks through the skin. It may rupture 
into surrounding organs or structures, as the vagina, bladder, and rec- 
tum. The appendix may become invaginated into the caecum and, by 
obstructing the blood-supply, become gangrenous, slough off, and be 
passed by the bowel. 

Ulceration following typhoid is often seen, and perforation is not 
unknown. In obliterative appendicitis the entire tube is thickened, firm, 
and stiff; the peritoneal surface is smooth or injected, and may be 
adherent or free. It may become cystic, the contents being clear fluid 
or pus. The situation of the appendix varies greatly ; rarely it may be 
found on the left side, as in transposition of the viscera, or it may be 
entirely absent. I have seen the tip of the appendix resting beneath 
a distended gall-bladder, entering into the formation of a left femoral 
hernia, or lying in the sigmoid flexure in a case of ileocecal intussuscep- 
tion. On microscopic examination the lymph-follicles are numerous 
and close together, but as age advances they become separated and 
smaller. Late in life the appendix undergoes marked fibrous change, 
which must be distinguished from obliterative appendicitis. Primary 
cancer and sarcoma of the appendix have been found in a number of 
cases. Lafforgue 1 reports a double hydatid cyst of the appendix. 

More people die from dysentery than from plague, cholera, and 
yellow fever. It occurs especially in warm climates and after eating 
improper food. I. Acute. — (a) Catarrhal, (b) Amoebic, (c) Gan- 
grenous. II. Chronic. In the early stages the bacillus of Chante- 
messe 2 is found, and in the later stages, especially where abscess 
develops, the amoeba coli is seen. The blood of patients affected with 
tropical dysentery has an agglutinative reaction with the bacillus of 

1 Gas. des Hbpit., January 12, 1904, p. 33. 

2 Commonly spoken of as the bacillus of Shiga, although described by Chante- 
MESSE and Widal in 1888. Presse med., July 23, 1902. For the latest information 
on this subject, see Diarrheal Diseases of Infancy, vol. i of studies from the Rocke- 
feller Institute for Medical Research. 



EXAMINATION OF THE ABDOMINAL ORGANS iyo 

dysentery. Summer diarrhoea of children has also recently been shown 
to be due to the same organism. All the lesions of dysentery have cer- 
tain points of election for the starting of the inflammatory process, — 
viz., the large bowel, the flexures of the large bowel, and the course of 
the valvulae conniventes. (i) Acute Catarrhal Dysentery. — The mu- 
cous membrane is enlarged, swollen, and covered with tenacious blood- 
stained mucus. The solitary follicles stand out prominently and in 
protracted cases often show necrotic or suppurative change. In some 
cases numerous ulcers appear throughout the large bowel. In children 
the picture is that of an acute follicular colitis. At first glance the 
mucous membrane seems to be universally congested ; on closer exami- 
nation it is found to be more or less streaky, with bright-red pin-point 
areas of intense congestion. The peritoneal surface is enlarged, lustre- 
less, and sticky. (2) Amoebic Dysentery. — In this form the amoebae, 
of which there are several kinds, both pathogenic and non-pathogenic, 
are almost always present. These are unicellular protoplasmic motile 
organisms, five or six times the size of a white blood-corpuscle. They 
contain a nucleus and one or more vacuoles. The characteristic lesion 
is an ulcer, which has a small external opening, with extensive under- 
mined infiltrated edges. Sometimes these ulcers run together, forming 
deep sinuous tracts bridged over by apparently healthy mucous mem- 
brane. There is a progressive infiltration of the connective-tissue 
layers of the intestine, causing pressure upon the blood-vessels and sub- 
sequent necrotic changes in the overlying structures, so that the mucosa 
or the muscularis may be sloughed off en masse in certain parts of the 
bowel. In severe cases the whole of the intestine may be much thick- 
ened and riddled with ulcers, with only here and there islands of intact 
mucous membrane. More rarely these ulcers have but slightly under- 
mined edges, the borders being more or less cleanly cut. In some cases 
there is a tendency to purulent formations. (3) Gangrenous Dysen- 
tery. — This form is characterized by the formation of a diphtheritic 
membrane, which is more or less irregularly distributed; it is at first 
yellowish-brown, in later stages becoming black or ashen-gray : in the 
latter case it appears as sloughs more or less easily detachable. There is 
thickening of all the coats of the intestine, with great interference with 
the blood-supply, so that in severe cases whole portions of the bowel 
may become gangrenous. (4) Chronic Dysentery. — In this form the 
anatomic changes are variable. Deeply pigmented ulcers are often 
present or there may be cicatrizations: again, no trace of ulceration 



[74 POST-MORTEM EXAMINATIONS 

may appear, but the entire mucous membrane presents a rough, irregu- 
lar, figured appearance, in places slate-gray or blackish in color. Cer- 
tain parts of the mucosa are greatly thickened and the muscular coat is 
hypertrophied. In some cases the solitary follicles are enlarged and 
pigmented. At times the outlets of tubules of the glands are closed, 
thus forming " slime cysts" (Orth), varying in size from a pin-head to 
a pea. The condition is called chronic cystic enteritis. The calibre 
of the bowel may be reduced, but stricture is very rare. Complica- 
tions. — (a) In all cases dysentery may be complicated by peritonitis, 
pleurisy, pericarditis, or pyaemic manifestations, (b) In amoebic dysen- 
tery the characteristic complication is the abscess of the liver, which is 
usually single and occupies the right lobe. It may be multiple, when 
it is apt to be distributed superficially in any or all of the lobes. It 
is a large solitary abscess, the wall of which is made up of broken- 
down, rough, shaggy liver-tissue, without any of the ordinary pyogenic 
membrane. The contents of this abscess vary. The outer portions are 
gelatinous and composed of broken-down liver-tissue, blood-pigments, 
pus-cells, amoebae coli, etc. The interior is usually of an almost watery 
consistency, and of a brownish or reddish color. In some cases cultures 
made from these abscesses are sterile. In hot climates the amoebae coli 
are almost always found on microscopic examination of old cases. 

In colitis, or inflammation of the large bowel, consider: (a) Early 
life, (b) Hot weather, (c) Improper foods, (d) Certain micro-organ- 
isms of the colon group, (e) Poisons, (f) Some infectious diseases. 
Classification. — (a) Simple, (b) Membranous, (c) Ulcerative, (d) 
Chronic. ( I ) In simple colitis the mucous membrane is much thickened 
and reddened, the rugae are prominent, and petechial hemorrhages are 
common. In ordinary inflammation the follicles are inflamed and 
cedematous and on section they appear like pearls. When there is a 
marked cell increase, they are white or gray and more prominent. These 
follicles may become confluent. (2) Membranous colitis is character- 
ized by the formation of a more or less complete cast of the intestine, 
usually from one to six inches in length, but it may extend a distance 
of several feet. The membrane usually appears homogeneous, but may 
be distinctly laminated and show deposits of fecal matter between the 
layers. The end of the cast may be well defined, but often shades off 
into a transparent gelatinous material. Associated are swelling and 
oedema of the submucosa. The mucous membrane not involved is very 
much inflamed and there may be hemorrhagic infiltration. The intes- 



EXAMINATION OF THE ABDOMINAL ORGANS T ~- 

tine may show that perforation has occurred and gangrene may some- 
times supervene. (3) In ulcerative colitis the appearances vary greatly : 
the ulcers may be small and numerous or they may be large in size and 
few in number. They may be perfectly regular in outline, but are 
usually irregular, with slightly undermined edges. The floor of the 
ulcer generally shows a somewhat sloughing bowel. The ulcers may 
communicate by the separation of layers of the intestines. In long- 
standing cases they are often intensely congested and tend to become 
transverse. Sometimes the floor of the ulcer becomes so thin as to be 
pushed out and form pouches. In very acute cases the mucous mem- 
brane is much reddened, highly vascular, and the surface is soft. The 
peritoneal coat of the bowel may be normal in appearance, but is usually 
red. somewhat sticky, and shows many dilated blood-vessels. Small 
hemorrhages are common. (4) In chronic colitis the bowel is often 
much thickened in all its coats. It may be larger in diameter. It is 
firm, even leather}', to the touch. The mucous membrane is hyper- 
trophied, often much pigmented, and shows many small hemorrhages. 
The follicles are swollen and have a slaty appearance. There may or 
may not be ulceration. 

There are four forms of dilatation of the colon: (a) Distention 
from gas. (b) Distention due to some solid substance within the 
bowel, (c) Distention caused by an organic obstruction in front of the 
dilated bowel, (d) The so-called idiopathic dilatation. 

Malignant disease of the colon is generally a cylindrical-celled epi- 
thelioma, usually confined at the start to a small area, where its con- 
traction sets up an annular stricture. 

The Kidneys and Adrenals. — The spleen and intestines having 
been removed and the liver turned over into the thorax, the kidneys 
and adrenals yet remain behind the peritoneum, often deeply embedded 
in the perinephrial fat. Of course, in anomalous cases, in certain dis- 
eases and deformities (notably Pott's disease), and in floating kidney 
they may be considerably displaced. In any event it is best and simplest 
first to find the ureters as they descend on the psoas muscles and enter 
the pelvis. The exact situation of the ureters is as follows: Each 
ureter at first passes obliquely downward and inward to enter the cavity 
of the true pelvis and then curves forward and inward to reach the 
base of the bladder. In its whole course it lies close behind the perito- 
neum and is connected to neighboring parts by loose areolar tissue. 
Superiorly it rests upon the psoas muscle and is crossed very obliquely 



i-o POST-MORTEM EXAMINATIONS 

from within outward by the spermatic vessels, which descend in front 
of it. The right ureter is close to the inferior vena cava. Lower down 
the ureter passes either over the common or the external iliac vessels, 
behind the termination of the ileum on the right side and the sigmoid 
flexure of the colon on the left. Descending into the pelvis, it enters 
the fold of the peritoneum forming the corresponding posterior false 
ligament of the bladder, and, reaching the side of the bladder near its 
base, runs downward and forward in contact with it, below the oblit- 
erated hypogastric artery, and in the male is crossed upon its inner side 
by the vas deferens, which passes down between the ureter and the 
bladder. In the female the ureters run along the sides of the cervix 
uteri and the upper part of the vagina before reaching the bladder. 
(Quain's Anatomy.) 

Incise the peritoneum on the left side first, then on the right over 
and in the direction of the brim of the pelvis, and follow up each ureter, 
gently tearing away the loose connective tissue, but' being careful not 
to disturb seriously the relationship of the kidney and adrenal and their 
vessels until they have been noted. If this method be adopted, there is 
no need of making an incision in the peritoneum directly over the 
kidney, as is recommended by most pathologists. A careful examina- 
tion of the vessels entering and leaving the kidney is next made, — 
vein, artery, ureter, etc., — all of them being subject to many anomalies. 
The left spermatic or utero-ovarian vein enters at right angles into the 
renal vein, which I have known to be followed out in mistake for the 
ureter. The organs may next be " shelled out" of their bed of cellular 
tissue and fat and the vessels severed, thus permitting their removal 
from the body. The adrenal 1 is then separated from the kidney, 
weighed, measured, and incised in its greatest plane. Should disease 
of the bladder or ureters be present, the kidneys may be removed from 
the body with the ureters attached. This is always better in those very 
common cases in which double ureters are found. One nick is then put 
in the left kidney at its upper or lower border, and the kidney and adre- 
nal are removed, or the kidney may first be dissected. Another method 
of distinguishing the right kidney from its fellow is to make a uniform 
rule as to which ureter shall be left the longer, by several inches, on 

1 The right adrenal is more difficult to find than the left, and may be permitted 
to remain in the body until after the removal of the stomach, duodenum, and pan- 
creas, but should be sought for before the removal of the liver. Testut, quoted 
by Gerrish, gives admirable illustrations of the situation of the adrenals. 



EXAMINATION OF THE ABDOMINAL ORGANS 



177 



the separation of the kidneys from the body. The kidney is then 
cleaned and weighed, and any peculiarities are noted. 

To remove the kidney while the intestines are still in the body, 
first hold aside the left sigmoid flexure and pull away the fundus of 
the stomach and the tail of the pancreas. Then make an incision over 
the convex border of the kidney. Xext separate it from the surround- 
ing tissue and cut the kidney out along with the adrenal. The right 
kidney lies under the liver, and in removing this adrenal be careful 
not to cut the inferior vena cava. If you remove the ureters with it 
(Fig. 95), on the right side a long incision must be made through the 
peritoneum that goes from the abdominal wall to the caecum and colon. 
(Orth.) Xauwerck recommends a more complicated method. He cuts 
the descending colon from the mesocolon first. His primary incision 
is vertical and between the hilum and the spinal column, a second one 
being made in the convex border of the kidney. 




Fig. 96 — Method of opening the kidney. The organ is held in the left hand with its hihim down- 
ward, and an incision is made with a brain-knife along its upper convex border and more than half 
through the renal substance. It is then reversed (Fig. 97) and the incision continued until the gland 
is nearly, but not quite, divided. In this manner there is no danger of cutting the hand. 

Holding the kidney longitudinally in the hand, the hilum towards 
the palm and the convexity upward, a clean brain-knife or large carti- 
lage-knife is used to divide it through its middle parallel to its greatest 
surface. The knife must be so sharp that it will cut without tearing, 
and care should be taken not to extend the incision through to the hand 
(Fig. 96). The wisest precaution for this purpose Is first to bisect the 
kidney only to its centre, then reverse the organ in the hand and com- 

12 



178 



POST-MORTEM EXAMINATIONS 



plete the incision by cutting outward (Fig. 97). The pyramids and 
the calices with their papillae will now be completely exposed and the 
two halves held together by the tissues composing the pelvis. If it be 
desired to lay open the hilum or a hydronephrosis, scissors should be 
employed. Precipitates of urinary salts in the pelvis are often mis- 
taken for pus. A microscopic examination, especially if acetic acid 
be added, will at once reveal the true nature of the fluid. Now exam- 
ine the surface for cysts, stellate veins (veins of Verhagen), aberrant 
adrenals, miliary tubercles, tumors, etc. Large cysts can readily be 




Fig. 97. — Method of opening the kidney in such a manner as not to injure the hands of the operator. 

seen. When incising a cystic kidney, it should be remembered that the 
liquid therein is often under considerable pressure, and may squirt 
several feet when the cavity is opened, and thus injure the eyes or soil 
the clothing of the operator or of those present at the autopsy. 

The capsule, which when normal is transparent, is next stripped off 
from one side (Figs. 98 and 99), and its condition noted as to whether 
or not it is thickened, adherent, or non-adherent. If adherent, see if 
any of the cortical substance is removed with it, — i.e., whether the 
inner surface is smooth or rough. In those cases where the capsule 
is adherent, this portion of the kidney should be saved for microscopic 
study along with the renal tissue lying directly beneath. The normal 
color of the surface of the kidney after removal of the capsule is brown- 
ish red. 



EXAMINATION OF THE ABDOMINAL ORGANS 



179 



. The relation existing between the lighter cortex and the darker 
medulla is determined by drawing a straight line from the apex of one 
of the largest central cones of a pyramid to the surface of the kidney. 
Normally this relation is as one (cortex) to three (medulla) ; it is, 
however, frequently altered and should always be noted. The cortical 
substance is increased in parenchymatous nephritis and decreased in 
chronic interstitial nephritis. Also study the color of the external and 
cut surfaces, the quantity of blood or fluid exuding and its character, 
and the consistence of the organ. Thus, in parenchymatous nephritis 
the color of the cortex is a grayish white or light yellow. In poisoning 
by hydrocyanic acid much blood exudes, and in chronic interstitial 
nephritis the nephritic tissue is dense and hard. Both anaemic and 
hemorrhagic infarcts occur. Scars are often found, and may be -due 
to many different causes, as gummata, thromboses, infarcts, stones, 
former operations, etc. Tumors of the kidney, especially fibroids, are 
quite common. With arteriosclerosis and granular kidneys, suspect 
apoplexy, especially if there has been a clinical history of flushing of 
the face. As a routine practice in the examination of the kidney, the 
amyloid reaction should be tried. A thin slice about one inch square, 
including both cortex and medulla, is removed from the organ and 
placed in Lugol's solution (which is preferably diluted four or five 
times) for several minutes and then examined with a hand glass in a 
good light. In weighing the kidney the fat which accumulates — as 
found in old renal cases in the renal hilum — is weighed along with the 
organ and unless its presence is mentioned may give a false idea as 
to the real weight. 

Where decapsulation as an operative therapeutic measure has been 
practised, also after the scraping of the hepatic peritoneum for ascites, 
the post-mortem examination should be very thorough, as any informa- 
tion concerning such cases is most important at the present time. 

The adrenals are covered by the under surface of the diaphragm, 
although not usually attached to it, and above and lateral to the tips 
of the kidneys. It is embedded in the same kind of tissue as surrounds 
the kidney, which is of a fatty cellular nature, the difficulty of finding 
the gland being in proportion to the amount of this tissue, which dif- 
fers, however, in its color unless stained with bile. A tier the gland 
is found, its dissection is best accomplished by a pair of scissors. It is 
sometimes intimately connected with the kidney or even with the liver 
by bands of fibrous tissue. Accessory adrenals (mostly found by 



jgo POST-MORTEM EXAMINATIONS 

microscopic study of other parts) are found at times in the neighbor- 
hood o\ the main gland or even several inches away. They may be 
iinu\i\ in the kidney ( hydronephroma) or even in the liver. The adre- 
nal of one side may in rare cases be absent. 

The adrenals are best removed attached to the kidneys, though, as 
already stated, the ablation of the right adrenal with the kidney is more 
difficult than that of its fellow, and for this reason it is often left in the 
body and examined at the time of the removal of the pancreas. The 
adrenals are very delicate, and care must be exercised lest they be in- 
jured in their excision. Normally the adrenals consist of three layers, 
which differ more or less in the young and the old. The outer or cor- 
tical layer is light yellow in adults and grayish red in children. This 
tissue somewhat resembles that found in the thyroid gland. It is com- 
posed of radiating follicles whose cells are undergoing fatty degenera- 
tion. It will be seen in the new-born that the adrenals are relatively 
of large size in comparison with the kidneys and when examined 
microscopically no fatty metamorphosis is discovered. The inner or 
medullary substance is composed of neuroglia and ganglionic cells 
connected with a rich vascular supply. The middle zone, or inter- 
mediary substance, is brown, owing to pigmentation of the follicles. 
The amount of intermediary substance is subject to considerable varia- 
tion. (Langerhans. ) Later in life there is a tendency for the central 
part to become separated from the intermediary portion, 1 and in atro- 
phy of this organ, when it takes place unevenly (as it frequently does), 
nodes are left on the surface w r hich are not infrequently mistaken for 
tubercles. These organs are subject to numerous pathologic changes 
and are hyperplastic in many varieties of congenital deformities in 
which other nerve-tissue is affected. There may be here hsematoma, 
melanoma, cysts, hypertrophy, glioma, primary cancer, echinococcic 
cysts, haematoid degeneration, tuberculosis, purulent infiltration, in- 
farcts, and internal proliferations. The recent discovery of the marked 
action of adrenalin would seem to show the presence of an internal 
secretion acting directly upon the vascular apparatus. It by no means 
follows that the adrenals will be found affected, either macroscopically 
or microscopically, in all cases of Addison's disease. Exquisite miliary 
tubercles are seen in the adrenals, and in advanced tuberculosis the 
caseating mass may reach the size of a walnut. 

1 Letulle considers the formation of a central cavity as usually due to trauma- 
tism in its removal or to post-mortem changes. 



EXAMINATION OF THE ABDOMINAL ORGANS jgi 

Addison's disease is most frequently seen in laborers between the 
ages of twenty and forty years. It may be due to: (a) Tuberculosis, 
simple atrophy, cirrhosis, hemorrhage, or tumors of the adrenals, (b) 
Inflammation or pressure of structures bordering the adrenals, (c) 
Changes in the semilunar ganglia and the sympathetic system. The 
adrenals are not infrequently tuberculous, and there is then a defi- 
ciency of the internal secretion of these organs. The brownish pig- 
mentation (bronze disease) is most marked on the chest. The spleen 
may be enlarged, as may also the thymus, if the latter organ persists. 
The stomach and intestines may show hypertrophied lymphoid follicles. 
Xo specific blood-changes have been observed. One of the most marked 
cases of pigmentation of the abdomen which I ever saw was that of a 
girl who had undergone an operation for the removal of a large der- 
moid cyst of the ovary. It is possible that in this case the semilunar 
ganglia or the adrenals were affected by pressure or otherwise. In two 
cases of primary sarcoma of the adrenal, and in one of general tuber- 
culosis with marked involvement by caseous tubercles of both adrenals, 
I observed no pigmentation of the skin at the time of the autopsy. 

The Semilunar Ganglia. — The semilunar ganglion or cceliac 
plexus, which receives the great splanchnic nerve and the pneumogas- 
tric, is situated behind the stomach and in front of the crura of the 
diaphragm, by the side of the cceliac axis and the root of the superior 
mesenteric artery, and close to the suprarenal body (Fig. ioo). It may 
also be found by tracing the nerves from the adrenals to their entrance 
into the ganglion. The ganglia should be carefully studied micro- 
scopically in all cases in which lesions are suspected in the adrenals or 
in the sympathetic system. The color and vascularity as well as the 
condition of the surrounding connective tissue should be noted. In 
cholera and typhus fever the ganglia are hyper?emic and may show 
evidence of the occurrence of hemorrhage (Rokitansky). 

The Ureters and Bladder. — The ureters may be distended with 
urine, as from an impacted stone, from cancer of the uterus, or from 
overfilling of the bladder. They are often double, most frequently 
uniting in their middle third, more rarely in the structure of the blad- 
der, but may enter this viscus by separate papillae. The ureters being 
slit open throughout their entire extent, the appearance of the mucosa 
is described, taking into account the color and character of any 
catarrhal exudate, should it be present. Many microscopists teach 
methods of diagnosing the situation of a lesion in the urinary tract 



[82 



POST-MORTEM EXAMINATIONS 



from the shape of the epithelial cells. A most interesting experiment 
is to take at a postmortem scrapings from the pelvis of the kidney, 
the ureter, bladder, and urethra, examine them under the microscope, 
and determine whether or not such a diagnosis is possible. Hemor- 
rhages, abscesses, papillary fibromata, the Distoma hcEmatobium, calci- 




Fig. ioo.— The relations of the pancreas, kidney, ureter, adrenal, and solar plexus are shown, the liver 
having been turned upward and the intestines shoved over to the right. 



fied bodies, etc., are found in the ureter. Miliary tubercles of the 
mucous membrane are seen, often of typical shape and large size. 

In some three hundred consecutive autopsies performed in one year, 
I met with three cases in which the ureter had been tied during abdom- 
inal operations on the uterus and its adnexa. The right ureter seems 
to be ligatured oftener than the left. In pregnancy there may be con- 
siderable pressure hydronephrosis. 

If it be desired to collect the urine for microscopic, chemic, or 
medicolegal examination, it should be drawn off into a sterilized vessel 



EXAMINATION OF THE ABDOMINAL ORGANS 



I8 3 



with a new catheter. Should strychnine poisoning be suspected, place 
a live frog in the urine, and if strychnine is present in any amount the 
frog will show the typical strychnine convulsions. Unfortunately, 
however, in strychnine poisoning the quantity of urine secreted is 
often very small, and the alkaloid is not always present in the urine 
of those dying from its effects. 

Pelvic Organs. — Removal of the Female Genitalia. — The parietal 
peritoneum is freed around the entire brim of the true pelvis by a cir- 



M^5 




Fig. iio. — Method of opening the uterus; the lines show the places for the incisions, one of which has 
already been started at the cervix. Letulle prefers to open the uterus posteriorly. 



cular incision, starting and ending at the symphysis pubis and including 
the anterior portion of the sacrum. Orth begins the incision between 
the rectum and the sacrum, while Schottelius recommends the ending 
of the incision at the posterior superior spine of the ilium. The body is 
then placed in the position seen in Fig. 10 1, and the thighs are sepa- 
rated. An oval incision is next made, starting above the external geni- 
talia, below the symphysis pubis, and ending behind the anus near the 



[84 



POST-MORTEM EXAMINATIONS 



coccyx ( which may be examined at this time), passing to the outside of 
the labia on each side. Traction is then made upon the soft parts 
towards the median line and the incision deepened, keeping as close as 
possible to the pelvic bones and taking care that the knife or scissors 
cutting in the direction of the long axis of the body does not injure the 
rectum, bladder, or external genitalia. It is now possible to remove the 
external genitals, bladder, and rectum through the abdominal cavity, or 
the internal parts through the oval incision exteriorly (Figs. 102 to 109 
inclusive). Whichever method is adopted, the muscles, fatty tissue, 




Fig. hi. — The uterus has been incised in the manner called for in Fig. no. The ovary and the tube 
are opened. The fimbriated extremity, the hydatid of Morgagni, and a corpus luteum are well shown in 
the illustration. 

and fascia holding the parts in place are to be severed without injury to 
the tissues desired to be preserved ; or an internal or external hysterec- 
tomy may be performed, if for any reason the external incisions should 
be avoided. If the ureters and kidneys have been left connected, they 
may be removed at the same time. The pelvic organs having been ex- 
cised, they are placed on a board upon the table in the same relative 
position that they occupied while they were in the body. The bladder 
is then incised anteriorly with the scissors on the median line from the 
fundus to the urethra, which should be opened. In the male, the pros- 
tate should be carefully observed. 1 The rectum is slit up along its 



1 Many obducents partially open the bladder while it is still attached to the 
body; indeed, the entire examination of the pelvic organs can be made with the 
parts in situ. 



EXAMINATION OF THE ABDOMINAL ORGANS jgr 

posterior wall, while an anterior incision is chosen through which to 
examine the uterus. When it is desirable to preserve the exterior of 
the bladder intact, the rectum may be dissected away and the womb 
incised posteriorly, or the bladder may be removed so as to permit of 
the nterns being opened up anteriorly. A transverse incision in the 
litems from the entrance of one oviduct to that of the other will give 
an opportunity for a study of their uterine termini, which are some- 
times rather difficult to find. Each ovary is completely bisected through 
its free surface, with the exception of enough tissue at the bottom to 
hold the two halves together (Figs, no and in). The oviducts are 
now opened. Ch. Robin has pointed out that the normal mucous mem- 
brane of the oviducts secretes a creamy material which, without a 
microscopic examination, may be mistaken for pus. For the method 
of closing the external opening, see directions under Figs. 102 to 109 
inclusive. The older the ovary the more it is cut up, irregular, and 
covered with cicatrices. 

Removal of the Male Organs of Generation. — In the male the 
bladder is pressed downward well towards the rectum, and the tis- 
sues thus put on a stretch are incised close to the under portion of the 
symphysis pubis. A circular incision is then made anterior to the 
rectum and as close as possible to the parts to be removed (seminal 
vesicles, prostate, Cowper's gland, bulbus, etc.) without injuring them 
or buttonholing the skin. The soft tissues of the penis (cavernous and 
membranous portions of the urethra) are dissected away from the skin 
from within the pelvis, traction being made to bring these parts into 
the pelvic cavity as fast as those above are loosened. The corpora 
cavernosa and corpus spongiosum being now fully exposed, they are 
incised transversely near the attachment of the prepuce, just below the 
corona glandis and fraenum. By pulling on the spermatic cords from 
above and pushing up the testicles from below, these organs are then 
removed together. To facilitate removal, a few cuts may first be made 
into the deep inguinal ring. The skin of the penis and scrotum is well 
stuffed with cotton, so that they may conform as nearly as possible to 
their original shape. A preliminary symphysiotomy may even be per- 
formed, or a V-shaped portion of bone taken from the symphysis pubis, 
or, if desired, after dissection of the testes and their appendages, they 
may be returned to their normal situations. Unless by an accidental 
perforation of the skin, — as the knife is working in the dark. — there 
need be no visible deformity, if this method be properly carried out. 



!86 POST-MORTEM EXAMINATIONS 

The rectum and the bladder and its component parts may be left at- 
tached or they can be separated, as preferred. The testicles may also 
be removed and examined by dissecting beneath the skin in front of 
the symphysis pubis until their situation in the scrotum is reached. 
They are then pushed up with the hand from below. The tunica vagin- 
alis and the spermatic duct and its vessels are then dissected out. 

The technic of my external method of examining the testicles, 
urethra, spermatic cord, etc., without mutilating or disfiguring the 
external genitals, is as follows. The penis is grasped with the left hand 
and drawn upward and backward over the symphysis pubis in such a 
manner as to expose its under surface and the scrotum. With the 
thumb and forefinger of the same hand a fold of skin is taken up at 
the point where the integument of the penis merges into that of the 
scrotum. This fold, which should be in the line of the long axis of 
the penis, having been drawn taut, incision is made across it at right 
angles to the line of the penis. If this transverse incision be not 
carried too far, it will leave an oval gap about an inch and a half in 
diameter when the fold of skin is allowed to fall back. This will be 
quite large enough to permit the proper execution of the subsequent 
steps of the operation, and the wound, after being sewed up, is so 
small that it is entirely concealed by the penis when replaced in its 
normal pendent position. The finger is next introduced into the 
scrotum and swept around so as to break up the delicate areolar con- 
nective tissue that forms the septum scroti and unites the dartos with 
the testes; then by slightly dilating the external wound the testicles 
can be removed from the scrotal sac. Next the root of the penis is 
grasped from within, and the extremely loose bands of connective 
tissue that unite the body of the organ to the integument are broken 
up, still using only the finger. These connections having been severed, 
the body of the penis can be drawn from its cutaneous sheath as far as 
the point of union of the prepuce with the tissues at the cervix, so 
that now the testes and the penis, as far as the glans, are exposed 
without their cutaneous investment. In severing the body of the 
penis from the glans and the tissue included in the inverted sheath of 
skin, great care must be exercised not to " bottonhole" the delicate 
structure of the prepuce. This accident can be avoided by amputating 
the glans at a point one- fourth of an inch from the corona (which 
can be plainly seen and felt through the delicate skin covering it) 
and carrying the incision parallel to its plane. The direction of the 




Fig. 112. — Author's method of examining testicles, epididymis, spermatic cord, etc., without 
disfigurement. The primary incision is made in the median raphe in such a manner as to he 
covered when the penis is returned to its normal situation. 



■feh. 'Ilk 






lyik^ 








B 



Fig. 113. — Testicles shelled out of the scrotum through the opening made in Fig. 112. 




[14. — Appearance of the male external genitalia preparatory to minute examination in the 

author's method of exposing them without disfigurement. 




Fig. 115. — Method of examining the seminal vesicles, which are exposed by incisions at the places 
indicated by the lines above the seminal ducts, a, a, edge of severed portion of peritoneum ; b, urinary 
bladder ; c, c, seminal vesicles ; d, d, spermatic ducts. (After Nauwerck.) 




FlG. 116.— Relations of the gall-ducts and duodenum. The gall-bladder in this case was packed with 
stones and one large one was found in the common bile-duct; the pancreatic duct communicated with 
the duodenum by a separate outlet, and a probe is seen emerging from the opening through which the 
bile normally finds its way into the duodenum. 



Hepatic artery 
Portal vein 
Ductus chole- 
dochus 



Gall-bladder 



Inferior vena 
cava 



Spermatic vein' 




A Portion of 
£> diaphragm 



Spermatic vein 



FlG. 117. — Examining the bile-ducts. The left index-finger is introduced into the foramen of YYinslow 
and supports the hepatic artery, the portal vein, and the ductus choledochus, into the latter of whil h a 
sound has been introduced and is seen coming out of the opening in the duodenum. I After Nauwerck.) 




Fig. iiS.— Method of examining the stomach, which in this case was markedly hypertrophied. Rubher 
gloves are very useful for this purpose. 




Fio. n. Removal ol the liver from the body. It is held in the left hand and an incision is made 
rds the operator. This stretches the diaphragmatic attachments of the large blood-vessels, so that 
they may readily be incised. 



EXAMINATION OF THE ABDOMINAL ORGANS xg- 

incision will be downward and forward, for in the position in which the 
integument attached to the cervix now holds the penis, the fraenum is 
in front. The amputation of the glans is most conveniently performed 
with scissors, the body of the penis being supported by the thumb and 
first finger of the left hand (Figs. 112, 113, and 114). 

Xauwerck describes the following method of finding the seminal 
vesicles. They lie as long, flattened organs on the lateral side of the 
spermatic duct immediately above the prostate and the posterior wall 
of the bladder. The fundus of the rectovesical excavation is held up, 
and the index-finger is placed in the incision in the prostate, the middle 
finger in the posterior wall of the bladder, and the thumb on the 
rectum, which on being pulled downward exposes the back part of the 
neck of the bladder, upon which rest the seminal vesicles. Or, cut 
through the peritoneum in the depth of the excavatio rectovesicalis, 
and dissect up the spermatic cord until the vesicles are reached. They 
are then to be incised and the duct opened up with a fine pair of 
scissors (Fig. 115). The mucous membrane of the seminal vesicles 
is of a brownish color, like that of the testicle. 

The Duodenum and its Ducts. — The duodenum may be slit 
while still in situ, or it can be excised together with the stomach, liver, 
and pancreas, and the whole dissected after removal from the body. 
If a careful dissection of the pancreas be desired, it is well to leave 
the duodenum attached to the stomach and not to dissect these parts 
away from the pancreas, which in the Russian language is so aptly 
called the " under-the-stomach gland." The length of the duodenum 
is determined by laying a string along the centre of its anterior sur- 
face and measuring the same. The gut is best opened with a knife, 
starting at the tied end about the centre of its anterior surface and 
with the enterotome cutting more and more to the right until at the 
pylorus the incision almost reaches the posterior surface of the duode- 
num (Figs. 116 and 117). Notwithstanding the presence of the 
glands of Brunner in the lower third of the duodenum, the appear- 
ance of the mucous membrane closely resembles that of the jejunum. 
The papilla, the outlet of the ductus choledochus communis, can usually 
be discovered if it be remembered that it appears as an elevation of 
the mucosa near the junction of the second ( descending) portion and 
the third (transverse or oblique) portion of the duodenum, about three 
and one-half inches from the pylorus, just below the head of the pan- 
creas, and towards the inner and back part of the duodenum. The 



[88 POST-MORTEM EXAMINATIONS 

duct runs for three-quarters of an inch in the muscular coat of the 
bowel, where it is usually joined by the pancreatic duct. A small 
magnifying-glass will often enable one to distinguish the papilla from 
the valvulae conniventes. Pressure upon the gall-bladder, as sug- 
gested by Virchow, will cause bile to flow out (but care must be taken 
not to dislodge a gall-stone, either here or in the cystic duct) and thus 
reveal the opening of the duct. Another way is to follow down the 
cystic duct, make a transverse incision in it, introduce downward a 
small probe or splint of broom until this emerges through the opening 
in the papilla, and then slit it with a knife or scissors. Orth says that 
if, after finding the head of the pancreas, the intestines are stretched 
transversely, the outlet will readily be discovered a little below the 
middle of the head. Congenital diverticula of the duodenum are some- 
times found, as well as those of the stomach and oesophagus. Acces- 
sory pancreatic tissue may be found hid in the walls of the duodenum. 
The canal of Wirsung and its accessory canal should be opened. For 
this purpose the transverse incisions stop at the centre of the gland, 
and the canal is hunted for. It is usually situated about the centre, 
is small in size, and is recognized by its pearl-like color. When found, 
it is dissected out until within about one and one-half centimetres of 
the ampulla, when a flexible probe or small grooved director is passed 
through the ampulla. The opening of the caruncula minor is often 
closed and the pancreatic fluid finds its way out from the portion of 
the pancreas drained by it by means of the ampulla of Vater, or the 
converse may be true. Branches from the canal of Wirsung, when 
dissected out, may lead to accessory pancreases. 

The Stomach and (Esophagus. — Unless poisoning is suspected 
(see pages 242 and 343), the stomach is incised along the greater cur- 
vature, a little belozc the cardiac orifice and a little above the pyloric, 
the contents are removed, and the openings examined, after which the 
incision is extended in both directions until the entire viscus is laid 
open. The mucous membrane may be washed by allowing a gentle 
stream of water, as from a sponge, to flow over it, but it should not 
be rubbed with the sponge. The organ may be opened and examined 
without removal from the body (Fig. 118). Should it be desired 
to find the artery from which a hemorrhage has occurred in a gastric 
ulcer, water is injected into the gastric artery supplying this area, and 
it will be seen to exude from the open part. The usual situation of a 
gastric ulcer is upon the posterior wall near the pylorus. Examples 



EXAMINATION OF THE ABDOMINAL ORGANS jgg 

of a carcinoma developing from the edges of a gastric nicer are some- 
times found. Guiteras has pointed out the frequency of small abra- 
sions of the mucous membrane near the pylorus and the collection of 
small round cells in this vicinity. I know of no extended series of 
examinations of the gastric contents made after death. In nine cases 
of pernicious anaemia, Arneill ! found free hydrochloric acid in none, 
whereas it was present in some of the gastric carcinomata examined. 

The contents of the stomach should be examined as to their quan- 
tity, consistency, reaction, odor, gas formation, foreign bodies, color, 
inflammation, and infectious granulomata. Blood coming from the 
lungs is apt to be mixed with air. frothy in character, and redder than 
blood issuing from the oesophagus or the stomach itself, where, if the 
vessel be of good size, large, compact, blackish-red lumps appear. The 
blood from cancer is blackish brown (the so-called coffee-grounds 
appearance) ; that from diapedesis. cirrhosis of the liver, and inflam- 
mations is a brownish homogeneous mixture combined with mucus. 
The biliary pigments often impart to it a yellowish or greenish hue. 
In peritonitis and in obstruction of the bowel the gastric contents may 
be fecal in character. 

The most unexpected articles may be found in the stomach, — gall- 
stones, hair-balls, scarf-pins, glass, rupees (in one case weighing 
seventeen and three- fourths ounces), hundreds of pins and needles, 
etc. Thus, eight teaspoons and seventeen other articles were removed 
by operation from a would-be suicide. 2 Thieves often swallow articles 
stolen. The larva? of the Dipterce, maggots of cheese, earth-worms, 
ascarides. taeniae, and Oxyuris vermicularis have been found. (Ewald.) 

The oesophagus is opened up along its anterior surface throughout 
its entire median extent, either while in situ, in case it has not been re- 
moved in the manner suggested on page no (Fig. 86), or after its 
removal from the body (Fig. 87). Its caliber may be directly deter- 
mined by graduated cones, or may be calculated by dividing its circum- 
ference by 3.14. Its linear measurements can be made after it has been 
laid open. The longitudinal folds can plainly be seen, and in their nor- 
mal state post mortem may be discolored. Note carefully the change of 
color and elevation of the oesophageal epithelium as it passes into that 
of the stomach. Sometimes it is wise to differentiate by placing in 



1 Amer. Med., January 16. 1904, p. 93. 

'Monitor, Bull, de Vacad. de mid., 1903. vol. Ixvii, no. 34- p. 210. 



190 



POST-MORTEM EXAMINATIONS 



M filler's fluid or in alcohol for several hours, thus coloring or bleach- 
ing the part. Diverticula are not uncommon, and an aneurism with 
a very small opening, usually slit-like, may rupture into the oesopha- 
gus. The collateral circulation is often established by means of the 
veins in the lower third of the oesophagus. Peptic, typhoid, syphilitic, 
and tuberculous ulcers occur here, as well as abscesses, congenital 
diverticula, and stricture due to a cicatrix, neoplasm, spastic con- 
tractures, etc. 

In cancer consider heredity, sex (more common in the male), age 
(average about fifty years), previous history of a gastric ulcer, and 
place of origin, inquiring particularly whether or not other cases have 
occurred in the same house. Cylindrical-celled cancers are found espe- 
cially at the pylorus, while squamous epitheliomata occur mostly at 
the cardiac end of the stomach. The tumor may be hard (scirrhous), 
soft (medullary), or colloid, (a) Scirrhus. — The growth starts as a 
small nodule, usually at the pylorus, often . sharply .defined, and very 
hard. It is whitish on section and no cancer-juice exudes from the cut 
surface. Stricture of the pylorus with hypertrophy and dilatation of 
the stomach is common. Connective tissue is very abundant and can- 
cer-cells are few. Ulceration occurs late in the disease, (b) Medul- 
lary. — This tumor tends to become larger than the previous one. It 
contains much less connective tissue and is therefore softer. It involves 
all the coats and is not circumscribed. It ulcerates very early and hem- 
orrhages are frequent. As in the previous instance, metastasis is very 
common, (c) Colloid. — This variety usually consists of gelatinous 
cancer-cells in a condition of colloid degeneration. It extends over the 
entire stomach and metastasis is very rapid. Metastasis in all the forms 
affects the various tissues and organs in the following order : lymphatic 
glands, liver, peritoneum, omentum and intestine, pancreas, pleura, 
lung, and spleen. The squamous variety is a somewhat flat tubular 
swelling involving the superficial layers. It may constrict the oesopha- 
geal orifice and cause atrophy of the stomach. Cases in which a can- 
cerous stomach has been removed entire during life demand special 
attention at the postmortem. 

Gastrectasis, or dilatation of the stomach, is due to : I. Pyloric 
Stenosis. — (a) Carcinoma, (b) Congenital conditions, (c) Hyper- 
trophy of the pyloric sphincter, (d) Cicatrix of an ulcer, (e) Peri- 
toneal adhesions. (/) Cancer of the head of the pancreas or other 
structure pressing on the duodenum, (g) Spasm of the sphincter. 



EXAMINATION OF THE ABDOMINAL ORGANS I9 i 

II. Atony of the Gastric Walls. — {a) From chronic gastritis, (b) 
Excessive ingestion of solids and liquids, (c) Traumatism, (d) Sur- 
gical intervention, (e) Serious infectious diseases. (/) Neurasthe- 
nia. (Hemmeter. ) At first there is hypertrophy of the muscular 
walls. Soon, however, interstitial sclerosis comes on. the stomach may 
become either pyriform or hour-glass in shape, and the mucous coat is 
thrown into exaggerated folds. As atrophy advances all the layers of 
the stomach become thinner; the bundles of muscles are separated by 
connective tissue ; the surface may show evidences of pigmentation and 
petechial hemorrhage; and while the serous surface sometimes remains 
unaltered, it is usually thick, pale, and opaque. 

Gastritis, or inflammation of the stomach : I. Acute. — (a) Errors 
in diet both as regards quantity and quality, (b) Irritant poisons. 

(c) Mechanical: external (severe injury to the epigastrium); local 
(fish-bone, etc. ). (d) Thermal (hot or cold ingesta). (e) Infectious 
diseases, (f) Psychic shock (grief, sorrow, etc.). (g) Extension 
of inflammation. II. Chronic. — (a) Follows repeated acute attacks. 
(b) Slow poisons (alcohol, tobacco, gout, rheumatism), (c) Diet. 

(d) Anaemia and chlorosis. 

I. (a) In simple gastritis the mucous membrane is hypersemic, 
swollen, and covered with profuse thick mucus. There are localized 
areas of ecchymosis and often small erosions. In severe cases there is 
considerable denudation of epithelium, with perhaps an exudate of 
grumous blood, (b) Phlegmonous or suppurative gastritis may exist 
in two forms : the abscesses may be small, multiple, and miliary, or 
they may be diffuse. The pyloric end is most commonly involved. The 
submucous and muscular layers are much altered, being swollen, 
cedematous, purulent, and sometimes even bloody. The mucous 
membrane overlying the abscess may be normal in appearance, it may 
slough off, or, again, it may be swollen and hemorrhagic. Abscesses 
generally grow towards serous and not mucous surfaces. On the other 
hand, the surface is sometimes studded with numerous areas of focal 
necrosis of a yellowish appearance, and, on section, may discharge 
pus. (c) Diphtheritic gastritis sometimes follows laryngeal or pha- 
ryngeal diphtheria, and frequently accompanies pyaemia, scarlet fever, 
variola, and malignant endocarditis. In this form of gastritis we find 
a variable number of circumscribed areas of false membrane firmly 
adherent to the underlying structures and leaving a raw surface when 
removed. It is apt to attack particularly the crests of the rugae. Hie 



H) _> POST-MORTEM EXAMINATIONS 

diphtheritic patches are usually surrounded by areas of more or less 
pronounced congestion, (d) In toxic gastritis the appearance of the 
viscus depends upon the amount of contained food at the time of 
ingestion and the concentration and kind of poison. If the latter is 
diluted, the mucous membrane alone suffers; if concentrated, all the 
coats max be involved. Alkalies appear to be more destructive than 
acids, the lesions produced resembling- those of an intense congestion, 
more or less localized. Around an area of necrosis is a brown-black 
eschar. In very severe cases perforation may follow. Sloughs or 
ulcers are almost invariably found where the poison has been concen- 
trated. Mycotic gastritis may be due to : (a) Anthrax, (b) Favus. 
(c) Thrush. II. Chronic. — (a) Hypertrophic. — Virchow calls a 
condition of the mucosa when there are swelling, cloudiness, and a yel- 
low color, gastritis parenchymatosa or glandularis ; it is due to poisons, 
as arsenic and phosphorus, to acute infectious diseases, to acute atrophy 
of the liver, etc. This may be localized or diffuse. In the former case 
numerous mucous polyps can be seen over the affected area. This vari- 
ety occurs in drunkards. These warty elevations show considerable 
cystic degeneration. In the diffuse variety the stomach is almost invari- 
ably enlarged and the walls are thickened, particularly the mucous coat, 
which is decidedly velvety both to sight and touch, slate gray in color, 
with insular, deeply injected areas of scarlet and brown-red thickened 
patches. Besides being swollen, rugae are often present in exaggerated 
folds. Petechial hemorrhages and areas of pigmentation are common. 
There are often evidences of previous ulcerations (cicatrices). The 
stomach frequently contains a variable quantity of thick, tenacious, 
sour-smelling, greenish mucus, (b) Atrophic. — When this variety of 
the disease exists the walls of the stomach become thinner. There is 
connective-tissue overgrowth, which by its contraction causes the epi- 
thelial cells to undergo degeneration and disappear. The mucous 
membrane is thin, smooth, and pigmented. 

In hemorrhage from the stomach, if the blood come from without, 
as from a rupture of an aneurism, the stomach presents but few 
changes. The blood may be fluid or clotted ; it may be bright red or 
dark in color. When the hemorrhage is due to actual disease of the 
stomach, this blood is apt to be coffee-brown. Petechial hemorrhages 
in the mucous membranes are common. Extensive hemorrhage from 
the wall of the stomach is most usually associated with gastric ulcer. 
Behrend reports the autopsies of three cases in which death resulted 



EXAMINATION OF THE ABDOMINAL ORGANS ^3 

from the diagnostic and therapeutic inflation of the stomach with car- 
bon dioxid gas. 1 

The Liver and Gall-Bladder. — The clinician, having felt the 
lower border of the liver during life, often wants to know its exact 
situation at the postmortem, and is disappointed, on reading the report 
of the autopsy, if he does not there find what he desires. The attach- 
ment and the presence of any lesions near the suspensory ligament are 
carefully noted. In the round ligament are sometimes found small 
collections of blood in places where this vessel has not become entirely 
obliterated. The bile may now be collected in a sterilized tube such 
as is described on page 347. The so-called " corset-line" produced 
by tight lacing may be due to other causes, as a pleuro-pneumonia or 
subphrenic abscess. 

The liver is removed from the body by severing its attachments to 
the diaphragm, falciform ligament, blood-vessels, and ducts, and break- 
ing up existing adhesions. For this purpose traction is made by intro- 
ducing the left hand behind the right lobe and raising the liver so that 
it hangs over the ribs of the right side (Fig. 1 19) . Nauwerck removes 
the organ by finding the hepatoduodenal ligament and then, intro- 
ducing the index-finger into the foramen of Winslow, pulling it some- 
what towards the duodenum and cutting, from right to left over the 
finger, the ductus choledochus to the right, the hepatic artery on the 
left, and, lastly, the portal vein with its four main branches lying 
between the two posteriorly (Fig. 117) and quite constantly distended 
with blood. The liver is then weighed and measured, and the color, 
normally of a chestnut brown, and the condition of the surface are 
noted. The true color of the surface of the liver is best determined 
from an examination of its anterior aspect, as its lower part is apt to 
be bile-stained and, being in contact with the intestine, is more apt 
to show post-mortem changes. The right and left lobes may sometimes 
be measured separately with advantage. I have sometimes made a 
tracing of the outline of the liver by cleansing it from blood, placing 
it on paper, and then drawing with a pencil its outlines, indicating 
in their proper places any lesions which may be noted or the areas from 
which pieces are cut for microscopic study. As blood, when fresh, 
is quite adhesive, the paper must not be folded until any blood which 
may be on it has dried. After examination of the serous surface of 



1 Med. News, December 19, 1903. 
13 



194 



POST-MORTEM EXAMINATIONS 



the gall-bladder and duct, the sac should be laid open by a longitudinal 
incision carried through the duct. To find the ductus choledochus, 
first note the situation of the gall-bladder and then follow down the 
cystic duct either with the eye or by dissection to where the hepatic 
duct joins it. The bile-duct running to the right of the portal vein 
may then be dissected out to its outlet at the papilla in the duodenum. 
In case the liver is to be removed at once, the dissection should be 




Fig. 120. — Method of incising the liver. Long parallel incisions are made from the right lobe to the 
left, care being taken not to cut entirely through the organ, which would prevent reconstructing it in its 
normal state, nor to extend the incisions so deeply as to injure the gall-bladder. If desired, the liver may 
now be turned and a second set of incisions at a right angle to the first may be made upon its posterior 
aspect. The structures of the under surface of the liver have been previously dissected out in a manner 
similar to that described in the case of the lungs. The history of the case will usually give information 
as to which of the vessels may have to be sacrificed in the dissection. On p. 344 will be found methods 
for injecting the vessels with different colored materials. 



continued beyond the place where it is to be cut. Should resistance 
be met with in the passing of a probe during the process of dissection, 
such a part should be at once investigated. The hepatic duct may be 
opened with scissors until it has branched several times in the sub- 
stance of the liver. A bacteriologic examination of the bile-ducts or 
gall-bladder may now be made. It will be recalled that the portal vein 
is formed by the union of the splenic and superior mesenteric veins 
and after running three or four inches divides in the liver substance 



EXAMINATION OF THE ABDOMINAL ORGANS IC;5 

into two main branches. The inferior mesenteric vein may empty 
into the splenic or superior mesenteric or take part in the formation 
of the portal vein. 

The liver is laid on its posterior surface and a series of parallel 
incisions about half an inch apart, which do not completely pass 
through the organ, are made, either longitudinally or, still better, trans- 
versely (Fig. 120). 

In pernicious anaemia the presence of free iron may be shown by 
placing a thin strip of hepatic tissue in a ten per cent, solution of 
potassium ferrocyanide for several minutes and then washing it thor- 
oughly with a two per cent, solution of hydrochloric acid. The pro- 
duction of a blue color (Prussian blue) indicates the presence of iron. 
When Lugol's solution is applied to test the presence of the amyloid re- 
action, it is well to remember that the glycogenic reaction is produced 
by the iodin. A weak solution of the violet of Paris is recommended 
by Letulle for securing the amyloid reaction. Observe : Bile-ducts : 
(a) caliber, — normally that of a thin goose-quill, may be closed or may 
be of the size of a finger; (&) gall-stones; (c) ulcers. Portal vein: 
(a) color of blood; (b) thrombosis; (c) caliber, — may be thin, as 
"result of old inflammation; (d) periphlebitis. I recall a case operated 
upon for cirrhosis of the liver where the postmortem showed an in- 
fected thrombus of the portal vein. Gall-bladder: (a) size; (b) 
adhesions; (c) tumors; (d) contents, — 1, bile (note its color, — light 
or dark yellow, reddish yellow, greenish yellow, — quantity, quality, 
etc.) ; 2, foreign bodies, — gall-stones; 3, mucous membrane, — thick- 
ening, change in color, and inflammation. Liver: (a) position; (b) 
size, — increased in parenchymatous inflammation, decreased in atro- 
phy : (c) form, — fissures or granular distortion of surface; (d) 
color, — brown or brownish red normally, yellow in fatty infiltration, 
dark brown in atrophy, gray in amyloid and interstitial overgrowth, 
ochre-yellow in acute yellow atrophy, green in icterus, or dirty green 
when decomposition sets in; (e) consistence, — normally rather hard 
(pitting soon disappears), increased in amyloid disease, the pitting 
remaining for some time, softer in parenchymatous affections and 
early stages of acute yellow atrophy, fluctuates in echinococcus cysts 
and abscesses; (f) capsules, — normally transparent, but thickened in 
chronic inflammation, syphilis, etc.; (g) section, — smooth, uneven, 
rough, or granular; (h) lobules, — notice thai they are separated by 
connective tissue, more distinct in cirrhosis, less SO in acute yellow 



1 96 POST-MORTEM EXAMINATIONS 

atrophy. It is well to remember that in man the separation of the 
lobules by the connective tissue of Glisson's capsule is not at all well 
marked. Observe whether the lobules are larger or smaller than nor- 
mal. Notice that the color is darker in the centre of the lobule than at 
its periphery (cyanotic induration). See if the periphery is yellow 
(fatty infiltration). On section note whether the tissues retract. 

Pancreas. — The position of the pancreas having been determined 
in the preliminary examination of the abdominal cavity, its isolation 
and detachment are attended by no difficulty unless there be disease 
of neighboring parts, in which case its removal may necessitate taking 
an additional viscus with it. Many students are singularly unfamiliar 
with the normal anatomy of the pancreas, the splenic artery often being 
mistaken for the pancreatic duct and the sensation of hardness which 
this gland normally imparts to the touch being regarded as an evidence 
of sclerosis ; the head and tail of the pancreas, too, are not infrequently 
left in the body and thus escape examination. In warm weather the 
pancreas is early affected with signs of decomposition, consisting in 
a brownish-red color, softening of its tissue, and the escape of a greasy 
brownish-red serum. Disease may extend from the pancreas to the 
portal vein, bile-ducts, pylorus, or duodenum, or from these organs to 
the pancreas. Hemorrhages, tumors, degenerations, calculi, 1 atrophic 
changes, cysts, etc., may be found in this organ. The possible presence 
of fat necrosis — a not infrequent cause of sudden death — should be 
borne in mind. The submucous, interstitial, or subperitoneal patches 
of pancreatic tissue in the wall of the intestine should not be forgotten. 
Thorel 2 describes seven cases of accessory pancreas, in the stomach, 
intestines, and mesentery, the opening, except in the latter case, going 
to the intestinal tract. Langerhans's islands were absent in nearly all 
the cases examined. 

Examination of the Retroperitoneal Lymph-Glands, Dia- 
phragm, Vena Cava, Chyle-Duct, etc. — The retroperitoneal 
lymph-glands, best exposed by dividing the vertebral attachments of 
the mesentery at its roots, may be thickened from inflammation (as in 
syphilis) or be the seat of primary tumors (especially sarcoma and 
lipoma), secondary cancer, amyloid degeneration, and tuberculosis, 



1 Muller, Proceedings Path. Soc., December 10, 1903. These stones may be 
found in the intestines. 

2 Virchozv's Archiv, vol. clxxiii, no. 2. 



EXAMINATION OF THE ABDOMINAL ORGANS jgy 

or may have undergone changes due to various other inflammatory, 
cystic, and systemic affections. 

Examination of the diaphragm may reveal the existence of hernia, 
abscess on the under surface, perforation (as in echinococcus cysts or 
amoebic abscess of the liver), trichina spiralis, inflammation of its 
serous investment, fatty degeneration and brown atrophy, hypertrophy 
(as in obstruction to normal respiration), atrophy (as in pseudo- 
hypertrophic muscular atrophy), etc. The muscular fibres of the dia- 
phragm may undergo granular, cloudy, or fatty degeneration. Atro- 
phy may arise from lesions of the phrenic nerve or as a part of a gen- 
eral muscular atrophy. Traumatic rupture and congenital deficiency 
are occasionally met with. 

The vena cava and the aorta should be inspected for signs of in- 
flammation, thrombosis, etc. To remove the aorta it should be grasped 
as high up as possible, drawn forcibly forward, and cut obliquely from 
within and above outward and downward. In order to secure a firmer 
hold one finger may be inserted in its lumen. (Orth.) Its elasticity 
should always be tested by pulling both longitudinally and laterally. 
The color should also be noted and the presence of atheromatous 
patches and plates described, especially when found around or near the 
point of exit of its various branches, a frequent cause of arterio- 
sclerosis. 

The receptaculum chyli rests behind the aorta, mainly on the body 
of the second lumbar vertebra, and between the pillars of the dia- 
phragm and the insertion of the psoas muscles. It arises from three 
roots which spread out over the third lumbar vertebra. As the tho- 
racic duct ascends, it crosses above the left azygos vein, and lies be- 
tween the aorta and the right azygos vein, and has a caliber of from 
three to eight millimetres. At the fourth dorsal vertebra it passes 
behind the oesophagus and opens into the left subclavian vein, at or 
near the entrance of the left common jugular vein. It is readily found 
by dissecting away, with an up-and-down movement of the tip of a 
grooved director, the cellular tissue situated at the top of the arch of 
the aorta and the oesophagus. This is near the left subclavian artery 
and before the duct which bends around this artery, like a shepherd's 
crook, to terminate in the vein. It has a rosy-white tint with longi- 
tudinal striae, and at this point gives off few collateral branches. The 
azygos vein is much larger and not nearly so elastic. It can be opened 
by splitting with a pair of fine scissors. The right thoracic duct emp- 



1() S POST-MORTEM EXAMINATIONS 

ties into the vena anonyma and collects the lymph from the upper part 
of the right thorax, neck, heart, and upper extremity. Failure to find 
the duct may he due to its previous removal while still attached to the 
descending thoracic aorta. Tuberculosis of the thoracic duct is quite 
common in abdominal tuberculosis. 

Abscesses in the psoas muscles may be secondary to Pott's disease, 
coxitis, perforation of the intestine, tumors, etc. Examine the spinal 
column for kyphosis, lordosis, and scoliosis. 

In death after fright and from chloroform narcosis, a large amount 
of blood is collected in the abdominal veins, as the result of vasomotor 
paralysis. 



CHAPTER XT 

DISEASES OF THE GENITOURINARY TRACT 

Kidney. — No little confusion exists in the description of the patho- 
logic lesions of the kidney, owing to the multiplicity of terms employed. 
A classification of renal diseases depending upon the structure af- 
fected is: i, epithelial (parenchymatous) nephritis; 2, fibrous (inter- 
stitial) nephritis; 3, vascular nephritis. It should be borne in mind 
that there is no such thing as a perfectly pure form of nephritis and 
that the condition which predominates gives the name to the lesion. 
For example, when we speak of parenchymatous nephritis, we do not 
mean that the epithelial cells alone are affected without involvement 
of the connective tissue, for it is entirely proper to describe a case 
as chronic parenchymatous nephritis in which the interstitial changes 
are beginning to predominate. The epithelial cells of any portion of 
the kidney may be affected primarily, hence the name glomerulo- 
nephritis, etc. 

Amyloid Changes. — These may be due to (a) prolonged suppu- 
ration (tuberculous or syphilitic), (b) chronic disease of the kidney, or 
(c) lack of cardiac compensation. The amyloid kidney is usually 
enlarged (the condition occasionally occurs in a contracted kidney), 
pale in color, and firm in consistency. The capsule is adherent in places 
and shows petechial hemorrhages beneath it. The cortex is increased 
in size. The glomeruli are first affected and usually prominent, 
although the cortex is pale in contrast to the somewhat reddish color of 
the pyramids. The organ has a bacony or waxy appearance. The 
urine contains albumin. The tube-casts are hyaline, waxy, or finely 
granular. (Edema of the extremities is common. 

Congenital Defects. — (1) Total absence. (2) Absence of one, 
with hypertrophy of the other. (3) Rudimentary, cystic. (4) Du- 
plication. (5) Partial coalition, usually lower end (horseshoe). (6) 
Remnants of fetal lobulation. 

Congestion. — (a) In traumatism the kidney is large; the capsule 
is tense; the color is dark red. On opening the capsule the contents 
are found to be soft and bulge out and blood drips freely from the sur- 
face of the section. The dependent portions are more congested than 

199 



jOO POST-MORTEM EXAMINATIONS 

the cortex. In passive congestion the organ is enlarged and firm ; the 
capsule strips off readily ; the cortex is wider than normal ; the surface 
on section looks coarse and connective tissue is plainly visible; the 
cortex is of a deep-red color and the pyramids are of a purple-red. 
Congestion may be due to (b) drugs, as cantharides or turpentine, (c) 
infectious fevers, (d) alterations of the circulation in the kidney itself 
or in the vena cava (rare), (e) valvular lesions of the heart, (/) dis- 
eases of the liver, or ( g) diseases of the lungs. Haematoma of the kid- 
ney occurs, sometimes reaching a large size and holding over a quart 
of blood and clots. 

Cystic Disease. — (a) Congenital cystic kidneys are greatly en- 
larged, so much so at times as to impede labor. There may be a con- 
glomeration of cysts varying in size from that of a pea to a small apple. 
In some cases no renal tissue can be seen without the aid of a micro- 
scope. The cysts are lined with flattened epithelium and contain a 
fluid in which are found albumin, blood-crystals, cholesterin, triple 
phosphates, and fat-drops, (b) Chronic nephritis (which see), (c) 
Adenocystomata, of similar origin as the corresponding cysts in the 
ovary, (d) Concretions block up the uriniferous tubules and press 
upon the still intact epithelial cells, which later become flattened and 
disappear. The stroma and vascular supply are next affected and a 
cystic condition is produced, or the disease may go on to the forma- 
tion of large concretions. 

Hydronephrosis. — The outflow of liquid from the pelvis of a 
kidney may be obstructed by (a) congenital deformities, as when the 
pelvis comes off too high up on the kidney, (b) twists of the ureter, 
(c) calculi, (d) morbid growths, or (e) cicatricial bands. There is an 
accumulation of non-purulent fluid, which by steady pressure produces 
an atrophy of the organ and a gradual distention of its pelvis. . The 
papillae become more flattened and disappear, and their place is taken 
by concave recesses in the medulla, which becomes narrower. In ex- 
treme cases the kidney may be converted into a large cyst with some 
imperfect septa. There may be an enormous quantity of the contained 
fluid or only a few ounces. It is yellowish in color and contains urea, 
uric acid, and sometimes albumin and sugar. There is usually com- 
pensatory hypertrophy of the opposite kidney. 

Infarcts. — (a) Calcareous infarcts extend through the tips of the 
papillae as stripes through one-half or more of the medulla, mainly 
along the canals, but also in interstitial tissue. There is effervescence 



DISEASES OF THE GENITOURINARY TRACT 2 0I 

on the application of hydrochloric acid, (b) Uric acid — found as acid 
ammonium urates in very young children and as acid sodium urates 
in mature years in cases of gout — may be deposited within the kidneys 
in the form of flakes (uric acid nephritis or gouty kidneys). In babes 
they appear as yellow radiations from papillae into medulla, and show 
that the child was born alive, as they occur only after breathing has 
taken place. Sodium hydrate dissolves the acid ammonium urates, 
(c) Haemoglobin occurs in haemoglobinuria. It exists in the canals 
first as lumpy brown, later as granular, and seldom as crystalline 
masses. Haematoidin crystals are seen where old hemorrhages were 
(Virchow). (d) Bilirubin infarct gives the bile reactions. It occurs 
in the icterous new-born, in acute atrophy of the liver, and in pro- 
gressive pernicious anaemia, (e) Infarcts caused by salts of silver are 
very rare. (/) Hemorrhagic infarcts, (g) Anaemic infarcts. 

Interstitial Nephritis. — In acute interstitial nephritis the whole 
kidney is increased in size; the color is uniform, making it hard to 
distinguish the border line between the cortex (which is swollen) and 
the medulla. The process is essentially a productive one. There is a 
marked migration of the leucocytes and the connective tissue undergoes 
proliferation. The cells increase in number and the intercellular sub- 
stance disappears. The pus-cells get between the epithelial cells and 
the lumina of the canals can no longer be followed. Such areas may 
be found anywhere in the kidney substance. The process is essentially 
due to pyogenic bacteria brought from the heart, as in malignant endo- 
carditis, or the uterus, as in puerperal sepsis. The process ends in 
abscess formation, often affecting the perinephric tissues. (Langer- 
hans.) A similar condition may start from without the kidney or 
extend up from the pelvis or further down the urinary tract. 

Chronic interstitial nephritis may start as an acute form, but most 
frequently affects alone the connective tissue of its stroma, the blood- 
vessels not being involved. The process naturally ends in contraction. 
The canals are freed from their epithelial cells and the glomeruli may 
be brought so close together as to touch each other. The capsule is 
adherent and the surface lumpy or granular and grayish red in color. 
The cortex is much smaller and may measure only a few millimetres 
in thickness, but its consistence is markedly increased. Compensatory 
hypertrophy may occur. If the canals are fatty they appear as yellow 
stripes or points. Cysts are common and are most marked at the junc- 
tion of the cortex and medulla. The vessel walls are thickened. Local- 



202 POST-MORTEM EXAMINATIONS 

ized interstitial nephritis is usually syphilitic, while the diffuse form is 
due to gout, lithsemia, lead, over-indulgence, etc. In the latter form 
we have granular atrophy, the so-called red granular kidney, in which, 
as contraction takes place, cysts are found. 

Movable Kidney . — ((7) Especially in females, (b) Due to absorp- 
tion of perinephric fat. (c) Repeated pregnancies, (d) Traumatism. 
(e) Displacement by tumors. As a rule, the displacement is not great. 
The kidney usually moves downward or upward and inward, generally 
rotating so that the outer border and upper end move forward and the 
hilum is directed inward and backward. Nearly all cases are associated 
with a medial displacement of the colon. The right kidney is the one 
most frequently affected. 

Parasites. — Of the parasites the following are found: (a) Dis- 
toma haematobium {Bilharzia hcematobia). (6) Filaria sanguinis 
hominis. (c) Echinococci. (d) Cysticerci. (e) Pentastoma. (/) 
Strongylus gigas. All are rare in this country. 

Parenchymatous Nephritis. — Acute diffuse inflammation of the 
kidney is due to: (a) Acute infectious fevers, (b) Poisons, — e.g., 
turpentine, arsenic, etc. (c) Traumatism, (d) Exposure to cold and 
wet. Macroscopically the organ is swollen, tense to the touch as the 
capsule is stretched, but the substance of the kidney is softer than 
normal, the color is gray to yellowish, and the stellate veins on the 
surface are prominent. The capsule strips off easily and is somewhat 
thinner than when normal. On slitting the capsule the renal substance 
bulges out. The cortex, which is increased in amount, is somewhat 
pale, swollen, and soft ; the glomeruli appear as minute red dots. The 
pyramids are distinct and striated. The radiations in the medulla may 
be gray or transparent, gelatinous or watery. The larger blood-vessels 
are overfilled and prominent. 

Parenchymatous Nephritis, Subacute. — The large white kidney 
is more swollen than in the acute form and the tissue itself is of 
greater consistency. The cortex may be increased, therefore, before 
contraction commences. Yellow spots where the degenerative changes 
are most marked are found in the gray glossy substance. Cysts are 
absent, unless interstitial changes are associated. The kidney is dry 
on section, and the pyramids of the medulla show reddened stripes 
pointing towards a papilla. This condition may be associated with 
amyloid degeneration, most marked in the glomeruli. The mucous 
membrane of the pelvis is frequently swollen and of a pinkish color. 



DISEASES OF THE GENITO-URINARY TRACT 203 

Microscopically the changes are those of an acute diffuse inflammation, 
including cloudy swelling, proliferation, desquamation, and a granular 
change in the cells lining the tubules. The straight connecting tubules 
may entirely escape, though there is a form of catarrhal nephritis, 
usually of an ascending variety, in which this part of the kidney is 
alone affected. In the surgical kidney there is an acute parenchymatous 
nephritis with abscess formations. Each individual cell is larger, the 
transverse diameter of the tubule increased, and the lumen diminished 
or even obliterated. Death most frequently takes place before the 
degenerative changes are complete; otherwise resorption and contrac- 
tion follow, and on the surface there are slight indentations, often asso- 
ciated with a hemorrhagic condition, hence bloody casts, as in poisoning 
by cantharides and potassium chlorate, where even pigmentary infarcts 
may be found. The urine is scanty, high colored, albuminous, and 
contains casts and free blood. There may be an extensive oedema, 
with effusions into the serous cavities. 

Parenchymatous Nephritis, Chronic. — This process is latent and 
runs a slow course, often of years; not all of the kidney is affected 
at once, some portions showing normal parenchyma while at other 
places degenerative changes are going on and at still others degenera- 
tion is complete and the parts are already in an atrophic condition. 
The cortex contracts irregularly, and has not the regular granular 
appearance seen in the kidney affected with interstitial nephritis 
(Langerhans), nor is there much increase in the stroma except at those 
places where contraction has taken place. 

Perinephritic Abscess. — (a) Traumatism. ( b) Extension of in- 
flammation from the kidney or from neighboring organs, (c) Per- 
foration of the bowel, (d) Infectious fevers, particularly in children. 
The kidney is surrounded by pus, especially posteriorly. The abscess- 
cavity is usually extensive. The pus is often offensive and may have a 
distinctly fecal odor. It may burrow and discharge into the lung, 
bowel, peritoneum, or bladder, or it may follow the psoas muscle and 
appear in the groin. 

Pyelitis and Pyelonephritis. — (a) Tuberculosis, (b) tnfectious 
fevers, (c) Calculi, (d) Cystitis, (e) Tumor-. 1 7 | Drugs. 
Cold and wet. Classification. — (a) Simple catarrhal. (b) Puru- 
lent, (c ) Plemorrhagic. (d) Calculous. In simple acute pyelitis the 
mucous membrane of the pelvis is swollen, hemorrhagic, and turbid. In 
the purulent form the mucous membrane is swollen and covered with 



204 



POST-MORTEM EXAMINATIONS 



a cream-like exudate of a yellowish or yellowish-green color. Ecchy- 
moses are common. The kidney itself is enlarged, softened, cedematous, 
grayish in color, and shows little distinction between cortex and 
medulla. Areas of necrosis or miliary abscesses are distributed through 
the kidney substance. The kidney may attain the size of a human head. 
It is usually firmly adherent to the adjacent organs, tissues, and vessels. 
A quart of pus may be contained in the cavity; in these extreme 
cases all appearance of the gland substance may be lost. The hemor- 
rhagic variety occurs in anthrax, sepsis, and leukaemia. In calculous 
pyelitis the mucosa is roughened, grayish in color, and thickened. 
There are also more or less dilatation of the calyces and flattening of 
the papillae. These may be covered by a gray membrane. After the 
renal substance has been destroyed, if the pelvic orifice is still obstructed, 
the pus may become inspissated and ultimately impregnated with the 
salts of lime. 

Stones. — The following varieties of stone may be found in the 
kidney or its pelvis: (a) Oxalate. This is very hard, dark, brownish 
yellow or gray in color, with rough surface and mulberry shape, (b) 
Uric acid. This is usually smooth or a little rough, light brownish 
yellow in color and often striped, and of medium consistence, (c) 
Phosphate stones are white, crumbling, and chalky, (d) Cystin and 
xanthin stones are rare. 

Tumors. — (a) Fibromata are the most common of benign tumors. 
(b) Lipomata. (c) Myxomata. (d) Myomata. (e) Angiomata. 
(f) Lymphadenomata (or lymphomata). (g) Rhabdomyomata. 
(h) Carcinoma may be primary or secondary ; it is comparatively rare. 
The cancer may infiltrate the whole cortex or may be knotty and sepa- 
rated sharply from the surrounding tissue, (i) Sarcoma may be 
primary or secondary. It is more common than cancer, usually occurs 
in children, and may attain to an enormous size. Here it exists as a 
myosarcoma. (/) Carcinoma sarcomatodes, (k) Patches of adrenal 
tissue may start growing and give rise to large tumors, the so-called 
hypernephroma heterotopes. Such growths are by no means rare. (/) 
Deposits of liver-tissue may be found in the kidney, especially in the 
cortical layer. 

Ureters. — In some malformed foetuses both ureters are absent. 
In other cases double bilateral ureters are found. They may open 
into the vagina or the uterus. Stenosis often occurs as a congenital 
or acquired condition. Cysts and polyps are found not infrequently. 



DISEASES OF THE GENITO-URINARY TRACT 20 ^ 

Parasites, as the Distoma hccmatobium, round worms, and echino- 
coccus, are found. A calculus may fill the pelvis of the kidney and 
extend down in the ureter. 

Bladder. — The color of the vesical mucous membrane is normally 
a pale gray, but is red in recent inflammation and blackish red if the 
inflammation be very severe. The mucosa affords a favorite location 
for the multiplication of various organisms, which usually reach the 
bladder either from the kidney or from the urethra. Typhoid bacilli 
may frequently be detected in the urine of patients suffering from 
typhoid fever. Cystitis is due to irritants in the urine, extension of 
inflammation from adjacent parts, traumatism, septic infection through 
the blood of the urethra, infectious diseases, stricture of the urethra, 
enlarged prostate, or diseases of the cord (myelitis) . It may be cedem- 
atous and especially hyperaemic after the ingestion of certain poisons, 
as phosphorus and cantharides. When caused by the colon bacillus, 
it may give the agglutinative reaction in a dilution of one to fifty of 
the blood of a patient suffering therefrom. In acute cases the mucous 
membrane is swollen, reddened, and covered with a thin film of mucus 
or pus. The veins may be distended, especially when hemorrhoids 
exist and venous thrombosis occurs. When hemorrhage has occurred, 
the surface of the membrane is of a universal gray tint or mottled with 
gray, black, or reddish-brown patches. In severe cases necrosis, ab- 
scess, or even perforation may occur. In the diphtheritic form of the 
disease necrotic patches are seen and also small hemorrhages in the 
region of the trigone and the surrounding fundus. These tend to 
increase in size. There is submucous swelling, which subsequently 
becomes infiltrated with pus. The whole mucous membrane over it 
degenerates and can easily be removed from the muscular coat. In 
chronic cystitis the bladder may be enlarged, but it is often smaller 
than when normal. The various coats are much thickened and there 
may be true hypertrophy of the muscular coat. This condition is best 
seen in cases of long-standing chronic cystitis, where the inner surface 
may even be thrown into folds and roughened so that the picture 
resembles that of the interior of a heart, and shows how difficult it is 
for injections into the bladder to cleanse thoroughly the walls when 
there is inflammation. In severe cases the inner coats often feel 
rough and sandy to the touch, on account of encrusted salts. Gangrene 
and tuberculosis may occur. There is a considerable variety of tumors 
in the bladder: adenoma, carcinoma, fibroma, myoma, sarcoma, and 



2o6 POST-MORTEM EXAMINATIONS 

mixed tumors. They frequently assume the form of polyps and villi. 
Cavernous angiomata, dermoids, and echinococcic cysts are met with. 
Pockets (diverticula) may develop in the walls of the bladder, some- 
times being covered only by the peritoneum. Their openings may be 
very small, though the size of each diverticulum may reach that of a 
hen's egg. These pockets are at times produced by and may contain 
stones. In exstrophy the inner surface of the bladder is exposed 
externally above the pubes through a hiatus in the median abdominal 
wall. The intestines may protrude into or open through the bladder. 
Professor Guiteras once related to me an interesting case of primary 
diphtheria which developed upon this exposed mucous membrane. 
The organ may be completely or partially divided by an anteroposterior 
septum. The bladder may be entirely absent or may be double. Cases 
have been reported in which the two bladders were of the same size 
and located the one behind the other. The remnant of the urachus 
may undergo cystic change. In hypertrophy dilatation of the cavity 
exists along with increase in the thickness of the wall, which may extend 
an inch or more. The female bladder may become inverted and appear 
through the urethra. It may also take part in hernias of various forms. 
The bladder may be ruptured by external violence, of which there 
may be no external visible sign. In over-distention from hemorrhage 
the bladder may reach to the umbilicus or may open into the rectum 
or vagina (vesicorectal or vesicovaginal fistula). In the interesting 
condition called trichosis vesicae the hair is usually referable to the 
breaking of a dermoid cyst into the bladder or it may be a product of 
growth from the mucosa itself. In one case — an autopsy on a female 
— I could not see where the dermoid had arisen if not in the walls of 
the bladder itself. In a body examined at the Pennsylvania Hospital 
a bundle of hair was found which had become encrusted with salts, 
thus forming a calculus. 

Garrod 1 gives the following causes of black urine: (i) jaundice, 
especially when of long standing; (2) hematuria; (3) hemoglo- 
binuria; (4) hsematoporphyrinuria ; ( 5 ) melanotic sarcoma ; (6) al- 
kaptonuria ; (7) ochronosis; (8) abundance of indican; (9) long- 
standing pulmonary tuberculosis; (10) the taking of certain drugs 
and articles of diet; (11) certain rare cases of undetermined nature. 

Vesical calculi, usually associated with some form of cystitis, may 

1 The Practitioner, March, 1904. 



DISEASES OF THE GENITOURINARY TRACT 20 y 

contain any of the normal or abnormal constituents of the urine. If 
this liquid be allowed to stand, precipitation occurs, the character of 
which depends upon the acidity or alkalinity of the urine. Bacteria 
in the body may cause an alkaline decomposition, with the formation 
from urea of carbon dioxide and ammonia, which uniting with the uric 
acid forms ammonium urates and triple phosphates. The most impor- 
tant sediments are uric acid, sodium urate, ammonium urate, — all of 
which give the murexide test, — calcium oxalate, calcium carbonate, 
calcium diphosphate, calcium triphosphate, and triple phosphate. Con- 
cretions may be found in the form of sand or as calculi. They are 
held together by an albuminous or cement-like substance, to which 
may be added cast-off epithelial cells, shreds of tissue, blood, mucus, 
etc. Primary stone formation may take place in urine which has not 
undergone decomposition; such calculi are usually composed of uric 
acid and urates. Secondary stone formation occurs in an alkaline 
urine, the starting-point being a foreign body introduced through the 
urethra from without or a small calculus which has found its way 
down from the kidney ; these stones are apt to be composed of ammo- 
nium urates and phosphates. They often consist of different substances 
concentrically arranged. Metamorphosed calculi are produced where, 
for example, a primary stone has been partially dissolved by the action 
of an alkaline menstruum and the remainder covered by secondary 
deposits. (Schmaus.) Calculi assume a large number of shapes and 
differ much in size. In addition to those named above, cystin and xan- 
thin stones exist. 

Parasites in the bladder are rare. The following have been found : 
(a) Distoma haematobium (Bilharzia lucmatobia). (b) Filaria san- 
guinis hominis. (c) Echinococci. (d) Cysticerci. (e) Pentastoma. 
(f) Eustrongylus gigas. 

Female Genital Tract. — Fallopian Tubes. — One Fallopian tube 
may be absent or rudimentary, and, on the contrary, I have seen an 
oviduct lengthened to over ten inches by traction from a growing 
uterine fibroid, and have observed in a tube extra openings supplied 
with fimbrice, the presence of which might at times have an important 
bearing upon the question of ectopic pregnancy. This dangerous con- 
dition may occur anywhere within the tube, or the fecundated ovum 
may escape into the abdominal cavity or become caught in a corpus 
luteum of either ovary. It is doubtful whether ovarian extra-uterine 
pregnancy ever existed: in two cases so diagnosed and brought to me 



2o8 POST-MORTEM EXAMINATIONS 

for examination, careful study showed that fecundation occurred near 
the ostium, and the fimbriated extremities became attached to the ovary 
just as in a case of ovarian abscess, making it to appear as if the preg- 
nane} had started in the ovary. Zinke tabulates a series of 88 cases 
of simultaneous intra- and extra-uterine pregnancies. An interesting 
abnormality is lithopaedion, where a foetus may stay in the abdominal 
cavity for thirty or forty years with certain of its tissues remaining 
recognizable. The convoluted interior of the oviduct offers a favor- 
able place for the growth of various organisms, especially the gono- 
coccus, the streptococcus, the colon bacillus, and the organism of tuber- 
culosis. The tube itself may be affected with cysts and with many 
kinds of benign and malignant tumors, the latter being primary or 
metastatic. It is subject to hemorrhages and different forms of in- 
flammation. 

In acute salpingitis the Fallopian tubes are swollen. The neigh- 
boring blood-vessels are dilated, tortuous, and overfilled with blood. 
There is often a considerable exudate on the serous surfaces, causing 
adhesions of the tubes to the surrounding structures. On section the 
lumen of the tubule is found to contain serum (hydrosalpinx), muco- 
purulent matter (pyosalpinx), or hemorrhagic fluid (hematosalpinx). 
The tube may rupture and give rise to a general peritonitis. The 
mucous membrane is thickened, swollen, and often intensely congested. 
To show the ciliated cells, though these may have been shed by the 
inflammatory process, care must be taken to harden the tissue at once 
after removal and according to the methods for showing karyokinesis. 
In chronic (proliferous) salpingitis the tubes may become enormously 
thickened, hard, and resistant to the touch. The adhesions to sur- 
rounding tissues are very marked and more or less completely organ- 
ized. The new connective tissue contracts, throwing the organs out 
of their proper relation and often obliterating their normal appearance. 

Ovaries. — These show perhaps a greater variety of pathologic 
changes than any other part of the body. The ovary may be divided 
into lobes by bands of connective tissue, or actual duplications of the 
parts may occur. Supernumerary ovaries are found. An ovary may 
form part of a hernia, and in a child I found one in the canal of Nuck. 
The organ may be absent, hypoplastic, or prolapsed in abnormal posi- 
tion. As the opportunity arises, study the differences between a true 
and a false corpus luteum and a corpus hsemorrhagicum. These glands 
are subject to various forms of inflammation, an entire ovary at times 



DISEASES OF THE GENITO-URINARY TRACT 20 g 

being converted into a pus-sac. They are often bound down by 
adhesions, and in later life undergo senile atrophy and may even 
become calcareous or calcareous concretions may be found in them. 
They undergo hypertrophy. Among the tumors here found may be 
mentioned adenomata, dermoid cysts, which are of an almost endless 
variety, enchondromata, endotheliomata, fibromata, fibromyomata, 
myomata, cancers, cystomata, sarcomata, psammocarcinomata, angi- 
oma, etc. Dropsy of follicles, fungous excrescences, and tuberculosis 
occur. Ovarian cysts may grow to an enormous size and contain over 
two hundred pounds of fluid. The ovaries may be enlarged in mumps. 

Uterus. — In examining the womb notice any abnormalities on the 
exterior and be sure to search every portion of the interior for any 
lesions which may exist. The situation of the organ may be markedly 
altered, both as to its entirety and its individual parts. Thus, we may 
discover anteflexion, anteversion, retroflexion, retroversion, prolapse, 
inversion, dilatations, elongations, bendings, or even find it forming 
part of an inguinal or a crural hernia. The chief congenital malfor- 
mations are uterus bicornis, bicornis duplex, bilocularis, subseptus, and 
bipartitus, unicornis, didelphys, cordiformis, septus duplex, and dou- 
ble uterus. The uterus is subject to atrophy, hypoplasia, rudimentary 
(infantile) atresia, stenosis, and hypertrophy. .Uterine tumors are of 
great variety, — adenoma, adenocystoma, cancer, deciduoma malignum 
(syncytioma malignum), hsematoma polyposum, fibroma, myoma, 
myofibroma, myosarcoma, lipoma, leiomyoma, etc. A placental polyp 
may assume destructive characteristics. Hydatid moles occur, and at 
times number several thousand. Fleshy moles are the result of hemor- 
rhage into the decidua. Dermoid cysts are found. Hemorrhages are 
common, and, besides those due to menstrual disturbances, are often 
associated with polyps, cancer, etc. After parturition and after the 
menopause marked changes take place in the blood-vessels, which may 
undergo amyloid degeneration. Infarcts are seen. Many varieties 
of endometritis exist, such as gonorrhceal, tuberculous, diphtheritic, 
syphilitic, decidual, fibrous, gangrenous, glandular, interstitial, ca- 
tarrhal, purulent, mycotic, villous, etc. Langerhans describes an inter- 
esting case of an old woman in which the womb was so enlarged by 
a solid mass of thrush fungi and other bacteria that it measured some 
two inches in diameter. The uterus may rupture, as from childbirth, 
trauma, etc. 

In acute forms of endometritis the mucous membrane is red, 

14 



2io POST-MORTEM EXAMINATIONS 

swollen, and sodden ; the discharge is profuse, stringy, and often puru- 
lent ; in severe cases blood is present. If infection follow contusion 
during labor, there may develop a suppurative process which trans- 
forms the parts into a soft, stinking, grayish-green or brown mass 
that tends to become gangrenous. The cervix is the most often in- 
volved. In diphtheritic endometritis there is formed a thick grayish- 
yellow or white membrane, the decidua lying loosely on the surface. 
The process may begin and remain at the placental insertion or may 
involve the cervical portion of the uterus. The infection may spread 
through the lymph stream or blood-vessels. Acute (ulcerative) endo- 
carditis is a frequent complication of puerperal infection. In hemor- 
rhagic endometritis the mucous membrane is red from engorgement 
of blood-vessels and numerous punctiform hemorrhages. It is dis- 
tinguished by the condition of the ovaries from a similar appearance in 
menstruation. Tuberculous endometritis sometimes resembles carci- 
noma in gross appearance, but on microscopic and bacteriologic exami- 
nation shows the presence of tubercle bacilli. 

In chronic hypertrophic endometritis there is a hyperplasia of the 
mucosa, with softening and congestion, forming polypoid excres- 
cences ; the glandular structures also hypertrophy, become occluded, 
and form cysts of various sizes. In the ceiwix enlarged Nabothian 
cysts should be looked for. In atrophic endometritis the mucous mem- 
brane becomes thin and pigmented and the glandular structures dis- 
appear. Follicular erosion of the cervix occurs after lacerations. 

Foreign bodies may be found in the uterus. These are introduced 
to prevent conception or to produce abortion, or find place through sur- 
gical manipulation or expulsion from some adjacent organ. Twenty- 
four hours after the birth of a full-term child the uterus weighs from 
seven hundred to twelve hundred grammes. Friable, elevated, mush- 
room-like fibrous masses formed after the removal of the placenta are 
found in the area where it was attached. 

/ r agina. — The vagina may be absent or appear as a mere connec- 
tive-tissue cord. It may be wholly or partially divided by a longitu- 
dinal or transverse septum. It may be entirely closed or so small that 
coitus, if attempted, takes place through the urethra, which thus be- 
comes markedly dilated. The normal flora is considerable, and of 
pathogenic organisms the Gonococcus, Bacillus diphtheria, and O'idium 
albicans (thrush) are of importance. It is well to remember that dip- 
locncci other than the Gonococci are frequently found in the vagina. 



DISEASES OF THE GENITO-URINARY TRACT 2 II 

After rape the condition of any secretion present should be noted, — 
whether dried, fluid, watery, or purulent; also its color and odor. 
Examine microscopically for spermatozoa and gonococci. Observe 
all discharges in cases of abortion. Severe inflammation may follow, 
and even gangrene may supervene. Erosions, fissures, fistula?, and 
lacerations are seen after labor. Syphilitic ulcers are common; those 
of a tuberculous nature are rare. Tumors of the vagina include 
cysts, carcinoma, fibroma, fibromyoma, myxoma, rhabdomyoma, and 
sarcoma. Malignant neoplasms of the cervix uteri may by extension 
of the growth involve the vaginal walls, which should, therefore, 
always be examined in such cases. The epithelioma is almost always 
cerrucose or nodose. Prolapse often accompanies tumors or is seen 
in multipara? accompanied by prolapse of uterus, rectocele, and cysto- 
cele. The exposed surface is eroded, covered with ulcers and patches 
of necrosis. Vaginal hematocele, hernia, abscesses, and hypertrophic 
vegetations are not uncommon. Poisons, as mercury, arsenic, have 
been found in the vagina. In cases of abortion various materials have 
been discovered. 

Male Genital Tract. — Testicles. — The testes are subject to 
many lesions, but the exposed situation and the extremely specialized 
character of these organs are sufficient to account therefor. The un- 
descended testicles are peculiarly liable to injury and the subsequent 
development of tumors. Adenoma, sarcoma, enchondroma, fibroma, 
osteoma, myxoma, and rhabdomyoma occur. Dermoids and mixed 
neoplasms containing cartilage are not rare. Inflammation is common. 
In typhoid fever the condition of the testicles should always be noted, 
as they may become infected with the typhoid bacillus. They may be 
affected by syphilis, tuberculosis, leprosy, etc. In guinea-pigs infected 
with glanders the testes are especially apt to become diseased. Sar- 
coma or a cancer of these organs is often indistinguishable. Cysts 
also occur, often combined with tumors. Hemorrhage may take place 
in the tunica vaginalis and the testicle may atrophy owing t<> pressure 
from the fluid in a hydrocele. True abscesses are found in them, and 
they may undergo brown atrophy, glycogenic infiltration, pigmentary 

amyloid changes. In elephantiasis they may show hypertrophy. 
The cords sometimes rupture and varix is common. Albers Schoen- 

g experimenting on guinea-pigs found that Rontgen ray- caused 
necrospermia Tin 197 minutes; and azoospermia ( 3-j minutes). The 
action of radium upon these organs should also Ik- studied. 



212 POST-MORTEM EXAMINATIONS 

Spermatic Cord. — The cord may become twisted; this condition is, 
as a rule, associated with undescended testicle or swollen epididymis. 
The cord may be thickened or lobulated. Its arteries sometimes show 
marked atheroma and its veins varices. I have also several times seen 
the duct itself converted into a rigid thickened tube by salt-like de- 
posits. 

Prostate. — The most common lesion of the prostate is enlargement 
due to interstitial hyperplasia. This is almost always accompanied 
by atrophy of the gland cells. Acute inflammation is very common. 
Abscesses occur; they are often not recognized until their sequelae 
are prominent, and are usually seen in the area around the posterior 
urethra. Cystic formation (cystic adenoma) is seen in many enlarged 
prostates, but true neoplasms are much less common. Carcinoma and 
fibroma are the most frequent. Moderate atheroma and endarteritis 
are seen almost always in the arteries of the part. In men over sixty 
years of age small prostatic calculi or sand, often dark in color, are 
quite commonly found on careful sectioning of the prostate. 



CHAPTER XII 

DISEASES OF THE LIVER AND PANCREAS AND THEIR DUCTS x 

Liver. — Abscess. — Hepatic abscesses may be multiple, often origi- 
nating from the appendix, or single, as in the amcebic abscess of the 
tropics. Perihepatitis is usually present, and rupture into the pleural 
cavity may occur. 

Acute Yellow Atrophy. — This is an acute disease of the liver, 
presumably of infectious origin, characterized by a rapid fatty degen- 
eration of the organ, with invariably fatal termination. Due to: (a) 
A specific micro-organism ( ?). (b) The ordinary micro-organisms of 
suppuration and infectious diseases have been found in this condition, 
(c) Certain poisons, — e.g., phosphorus, (d) Female sex. (e) Preg- 
nancy or the puerperium. The liver is greatly reduced in size, — one- 
half to one-third ; in one of my cases, however, the condition had been 
preceded by hypertrophic cirrhosis and the organ weighed over five 
pounds. The liver is thin, flattened, and flabby, the capsule is wrinkled, 
and the gland is of a pale-yellow color. Both on the surface and on 
section may be seen a number of orange-yellow patches, in the centre 
of which are usually marked hemorrhagic areas. The remainder of the 
liver is of a yellowish-brown or mottled color. The outlines of the 
lobules are very indistinct. The bile-ducts and gall-bladder are empty. 
Bilirubin crystals may be seen under the microscope. If a section of the 
liver be allowed to remain in the air for some time, a thin, white coating 
appears on its surface, which on examination is found to consist of 
crystals of leucin and tyrosin. The adjacent organs are usually stained 
with bile and present numerous hemorrhages, especially on the surface. 
The spleen is enlarged and the heart and kidney show marked granular 

1 Those wishing to go more deeply into this subject will find Waring' s Diseases 
of the Liver, Gall-Bladder, and Biliary System (1897) and Opie's Disease of the 
Pancreas (1903) most instructive reading. Virchow's remark in his " Post- 
Mortem Examinations" (1876) of "the slight importance of the pancreas" is in- 
teresting as showing the small consequence attached even until a short time ago to 
the functional activities of this gland. An account of the " Zuckergussleber" and 
fibrous polyserosities will be found in Rose, Wurzburger Abhandlungen aus dem 
Gesamtgebiet der prakt. Medizin, 1904, vol. iv, no. 5, and Kelly, Trans. Coll. of 
Phys. of Phila., 1902, p. 62. Cammidge's article on the chemistry of the urine in 
diseases of the pancreas is contained in the Lancet of March 19, 1904, p. 782. 

213 



214 



POST-MORTEM EXAMINATIONS 



change. The color of the liver in acute yellow atrophy depends on the 
time at which death took place : in the earlier stages the organ is ochre- 
yellow, in the later stages it is mottled, and if much blood be present it 
is grayish red. 

Amyloid Degeneration. — Found in cases of: (a) Prolonged 
suppuration, tuberculous or syphilitic, (b) Infectious fevers, (c) 
Chronic visceral diseases with cachexia. The liver is large in size, 
smooth in outline, and pale in color. The edges are distinctly rounded ; 
small hemorrhages are common on the surface. On section the surface 
is anaemic, semi-transparent, and infiltrated. It presents the character- 
istic lardaceous or waxy appearance. The process may be a localized 
or a generalized one; in either case staining by Lugol's solution is 
never uniform, as the diseased brown spots appear only in certain areas. 
The characteristic coloration may be seen upon the lining of both 
hepatic and portal vessels. Early in the disease this reaction is hard to 
detect, except by special stains under the microscope. Very thin pieces 
of the liver should be sectioned with a scalpel and put in a small glass 
dish. Add a solution of iodin and then wash out with water. Put 
something white under the dish and the characteristic coloration can 
be more readily seen. 

Bile. — T. Kimura 1 has investigated the bile taken from the human 
gall-bladder shortly after death. He finds its pigments to be variable 
in quantity, being low in tuberculosis and high in conditions of stag- 
nation, such as heart disease. The specific gravity varies from 1012 
to 1040, and the dry residuum from 2.68 per cent, to 20.63 per cent. 
The relative viscosity varies widely, — from 1.46 to 58.24. These fac- 
tors are all greatly increased in cases of obstruction of the common 
bile-duct. Urobilinogen is found regularly, urobilin very frequently; 
but both are wanting in cases of complete biliary obstruction, marked 
diarrhoea, and in the new-born. This fact supports the enterogenous 
theory as to the formation of urobilin. Normal faeces contain urobilin 
regularly, but it is wanting in cases of biliary obstruction. Meconium 
does not contain any. In a case of obstruction of the cystic duct, a 
hitherto undescribed brown pigment was found. 

Cancer. — T. Secondary Cancer. — Most common. Histologically 
shows same structure as primary growth, which is usually in the 
stomach, bowel, or pancreas. The liver is enormously enlarged, irregu- 



1 Deut. Arch. f. klin. Med., 1904, vol. lxxix, p. 274. 



DISEASES OF THE LIVER AND PANCREAS 



215 



lar, and nodular. The nodules are usually symmetrical, often super- 
ficial, flattened, discrete, and umbilicated ; they may be more or less 
evenly distributed throughout the liver. On section whitish masses of 
varying- size are seen, contrasting with the red color of hepatic tissue, 
the yellow staining of bile, pigmentation due to blood, and the light- 
yellow areas of fatty degeneration. The cancerous masses may undergo 
fatty degeneration, suppuration, or fibroid change. II. Primary Can- 

—Rare, {a) Massive. Causes great enlargement. On section the 
mass is uniform grayish white in color, somewhat firm, and distinctly 
outlined from the liver substance, (b) Nodular. Large and small 
nodules are scattered throughout the organ. These usually consist of 
a primary growth and numerous secondary nodules, (c) Cancer with 
cirrhosis is rare. Liver not much enlarged. Surface of section is 
grayish yellow, studded with nodular yellowish masses. In one of my 
cases of primary cancer of the gall-bladder the cancerous portions and 
the liver had become infected by the Bacillus pyocyaneus. 

Cholecystitis. Acute Infectious. — There exists an acute inflam- 
mation of the gall-bladder due to: (a) The introduction of pyo- 
genic micro-organisms, — for example, the Bacillus coli communis and 
the typhoid bacillus, pneumococcus, staphylococcus, and streptococcus. 
(b) Gall-stones, (c) Extension of inflammation from the bile-ducts. 
The gall-bladder is distended ; its walls are thickened and tense. The 
mucous membrane is swollen, hyperaemic, and may be covered with a 
purulent exudate. The submucosa may also be involved. The contents 
of this sac are cloudy and dark in color, and may be mucopurulent or 
hemorrhagic. Orth states that the inflammation is usually of a necrotic 
character. The tissue is of a dirty yellow-brown color and sometimes 
is rotten and easily torn. Gall-stones are frequently present. The 
cystic duct is often obliterated. There may be adhesions with the bile- 
duct or omentum. The common bile-duct may be congenitally absent 
and yet the child may live five months. 1 The gall-bladder may be 
absent without serious impairment of the hepatic function. 

Cholelithiasis. — Gall-stones may be formed within the gall-blad- 
der or in the ducts leading to or from it. Consider: (a) Most fre- 
quent in females, (b) Age, fifty per cent, over forty years old. (c) 
Sedentary habits. ( d) Overeating, (e) Carcinoma ( ?). (1) The 
calculi are usually multiple, rarely single. They vary in size as well as 



1 Menzies, Australasia Medical Gazette, January 20, 1904, p. 20. 



2i6 POST-MORTEM EXAMINATIONS 

in number. When multiple they are faceted, sometimes mulberry- 
shaped. They are of a dark bluish or greenish color. On section there 
is a nucleus consisting of epithelium, rarely a foreign body, then comes 
a layer of inspissated bile-salts, the outer covering being cholesterin. 
There may also be bile-acids, fatty acids, salts of calcium and magne- 
sium, with a trace of iron and copper. When the stones consist of 
pigment exclusively, they are very easily broken and vary from yellow- 
ish brown to black in color. When composed of cholesterin entirely, 
they are softer, easily indented with the finger-nail, but not brittle, and 
are crystalline, the crystals forming layers. They are colorless and 
more or less transparent, but turn blue when iodin and sulphuric acid 
are added. They generally consist of both pigment and cholesterin, 
which may be combined or may be separated by layers. These stones 
are usually firm in consistence, rarely friable. (2) The gall-stones 
may lead to impaction of the gall-bladder or to obstruction of the cystic 
and common ducts or even of the bile-duct alone. There may be forma- 
tion of a fistula, external or internal, with escape of bile. The bladder 
itself is much thickened, sometimes dilated, sometimes smaller than 
normal through chronic inflammation. 

Cirrhosis. — Under this heading are classified various forms of 
disease of the liver characterized by a marked increase of its connective 
tissue, which may be capsular; interlobular, or intralobular, with or 
without increase or decrease in the size of the organ. Causes: (a) 
Alcohol, (b) Certain infectious diseases, — e.g., syphilis, tuberculosis, 
malaria, scarlet fever. (c) Micro-organismal infection. (d) Me- 
chanical obstruction to the onward flow of the blood, (e) Rickets. 
(f) Anthracosis. (g) Poisons, as phosphorus and cantharides. Clas- 
sification. — (a) Alcoholic, (b) Fatty, (c) Hypertrophic, (d) Cap- 
sular, (e) Syphilitic, (f) Cyanotic, (g) Malarial, (h) Scarla- 
tinal, (i) Tuberculous. (/) Rhachitic. (k) Anthracotic. (1) In 
the atrophic cirrhosis of Laennec the organ is greatly reduced in size, 
although in the beginning it may be slightly enlarged, and later is 
altered in shape. The surface is irregular and nodular and the capsule 
thickened. The nodules are usually small, but in some cases they may 
be greatly increased in size. The tissue is firm, hard, and resistant to 
the knife. The surface of section presents a mottled appearance, the 
lobules being divided by bands of connective tissue. The liver sub- 
stance itself is of a yellowish or greenish-yellow color. The areas of 
connective tissue which are periportal are gray. (2) In fatty cir- 



DISEASES OF THE LIVER AND PANCREAS 2 l? 

rhosis, found usually in drunkards, the organ is enlarged, somewhat 
smooth, although often slightly granular. It is paler than normal and 
of a yellowish-white color. It is firm and resistant to the knife. The 
capsule is opaque and often much thickened. The peritoneal cavity 
usually contains ascitic fluid. The membrane is opaque and thickened. 
Chronic involvement of the stomach and small intestine is always pres- 
ent. The spleen is enlarged ; the kidneys are often cirrhotic. Owing 
to interference with the portal circulation by the cirrhotic liver, exten- 
sive compensatory circulation is formed. The abdominal vessels above 
and below the umbilicus are markedly enlarged. Around the umbilicus 
is found the caput of Medusa. Acute tuberculosis of the peritoneal 
cavity may be associated with it. (3) Hypertrophic cirrhosis is 
most common in young men. Ackerman compares it to elephantiasis. 
The organ is enlarged, but the outline is normal. The surface is usually 
smooth and its color an olive-green; the consistency of the organ is 
increased and the capsule is thickened. The surface of section is uni- 
formly greenish yellow and the lobules may be separated by distinct 
bands of connective tissue. The spleen is greatly enlarged. Jaundice 
is a marked symptom of this disease. Ascites is usually absent. (4) 
In capsular cirrhosis there is enormous thickening of the capsule, which 
is irregular and somewhat wrinkled, producing great contraction of the 
liver. The organ itself is rarely markedly cirrhotic, its tissue being 
usually soft. Chronic capsulitis of the spleen, chronic perisplenitis, and 
ascites are often present. The kidneys usually show granular change. 
(5) In syphilitic cirrhosis the liver is markedly irregular in shape, 
being divided into peculiarly shaped lobes by extensive bands of fibrous 
tissue traversing the organ in indefinite directions. In one of my cases 
over forty distinct lobulations were present. The cut surface is mottled, 
often fatty in appearance, and shows the presence of gummata or of 
syphilitic scars. The connective-tissue bands are of a gray or reddish- 
gray color. ( 6) For cyanotic cirrhosis see Passive Congestion of the 
Liver. (7) In malarial cirrhosis the liver is markedly enlarged, com- 
monly extending to the level of the umbilicus. It is firm in consistence, 
dark-red color, smooth in outline, and bleeds freely on section. 
( 8 J Klein has pointed out that chronic interstitial hepatitis may follow 
an attack of scarlet fever, which may account for some cases of cirrhosis 
of the liver in children, (cj) Rhachitic cirrhosis is a form of the dis- 
ease in which there is a marked increase of connective tissue around the 
individual lobules. (10) Anthracotic cirrhosis occurs in coal-miners. 



2i8 POST-MORTEM EXAMINATIONS 

in whom the coal-dust may occasionally reach the liver in sufficient 
quantities to cause a marked connective-tissue formation about the 
portal canal. (Welch.) Sears and Lord from a study of seventy-eight 
autopsies of hepatic cirrhosis consider the condition to be part of a 
systemic disease. 

Congestion. — (a) Acute infectious diseases. (b) Traumatism. 
(c) Extension of inflammation, — e.g., from the intestines, (d) Val- 
vular heart-disease, (e) Pressure of tumors. (/) Other mechanical 
obstructions to the circulation. The condition is most marked when the 
veins of the liver are closed, as in periphlebitis or Chiari's endophlebitis. 
( i ) The post-mortem appearances of active congestion are not char- 
acteristic. The liver is swollen, dark in color, and full of blood; the 
hyperemia is not limited to any one portion of the liver substance. 
(2) In passive congestion the liver is large in size, smooth or slightly 
granular in outline, and of a distinctly mottled hue. The surface of 
section presents the characteristic nutmeg appearance (the centre of the 
lobule being deeper), due to a marked congestion occurring in the 
central veins, the congested tissues being of a reddish-brown color. 
This is surrounded by a large area of a pale-yellowish color (fatty 
infiltration), with a third zone of cellular infiltration and new con- 
nective tissue. In rare cases this order is reversed, the congested area 
occurring at the periphery of the lobe and the lighter or fatty parts 
towards the centre. In chronic and well-marked cases there may be 
considerable induration and shrinkage of the liver substance, with 
irregular surface, so that the hypertrophy gives place to an atrophy, 
called cyanotic atrophy or Virchow's red atrophy. 

Emphysema. — Portions of the liver when squeezed under water 
show the escape of bubbles. This condition may be due to putrefaction 
or to the growth of gas-forming organisms during life. 

Fatty Changes. — (a) Middle life. (b) Alcohol. (c) Seden- 
tary habits, (d) Infectious fevers, (e) Certain poisons. (/) Ca- 
chexias, (g) Interference with local or general circulation. Classifi- 
cation. — (1) Fatty degeneration. The liver may be increased or 
diminished in size. The capsule may be smooth or wrinkled. The 
consistence is usually somewhat decreased; the organ is paler than 
normal and somewhat mottled in appearance. Periphery of lobule is 
first involved. The surface of section is smooth, usually bloodless, and 

1 Bost. Med. and Surg. Jr., September 11, 1902, p. 285. 



DISEASES OF THE LIVER AND PANCREAS 2I g 

imparts a greasy stain to the knife. The general color is a dull gray or 
grayish yellow. (2) In fatty infiltration the liver is often markedly 
enlarged, normal in outline, smooth to the touch, and of a somewhat 
pale, excessively fatty color. Globules of fat may be readily expressed 
with a knife. Hyperaemia may obscure the characteristic appearance. 

Hepatitis. Suppurative. — Abscess of the liver may be due to: 
(a) Traumatism. (b) Extension from neighboring organs, — e.g., 
the bowel and the pleura, (c) Pyaemia. (d) Amoebic dysentery. 
(e) Malignant emboli, (f) Diseases of veins, as periphlebitis, throm- 
bophlebitis, and thrombo-umbilicalis. (g) Stoppage of bile, as from 
gall-stone or dead ascarides. (h) Idiopathic tropical disorders. Clas- 
sification. — (a) Pyaemic hepatitis, (b) Portal pyaemia, (c) Pyo- 
septicaemia or multiple abscess, (d) Tropical or endemic hepatitis. 
(e) Suppurative cholangeitis. (1) In multiple abscess the change in 
the liver depends upon the number of the abscesses. If these be few, 
the liver walls may be comparatively little altered; if they are very 
many, the liver is apt to be enlarged, softened, and friable. The ab- 
scesses themselves appear as minute foci which are non-encapsulated, 
the centre containing a thick white, yellow, or greenish pus surrounded 
by a zone of congestion. The abscesses may number from five to ten, 
or many hundreds. These multiple abscesses frequently arise from 
pyaemic embolism of the portal vein or hepatic artery or vein, or they 
may result from a cholangeitis. They may be generally distributed or 
appear in clusters. If from a malignant endocarditis, they are usually 
situated under the capsule. ( 2 ) Large abscesses occur in two forms, — 
the large chronic encapsulated abscess surrounded by a pyogenic mem- 
brane and the tropical or amoebic abscess. (See Dysentery.) The 
large abscess is usually single; there may be two or more. The right 
lobe is usually affected. There is a distinct limiting membrane. The 
pus is usually of a greenish-yellow color and often of a disagreeable 
odor. The surrounding substances often show but few changes, except 
as the result of pressure. 

Sarcoma. — This may be primary (very rare) or secondary. The 
most frequent variety is the secondary melanosarcoma following sar- 
coma of the eye, of the skin, or of the penis. In these cases the liver 
is greatly enlarged, weighing as much as fifteen pounds, and the sec- 
ondary nodules, which are of a black or slate color, are usually uni- 
formly distributed throughout the gland. In primary sarcoma of the 
liver there are but few nodules, and these reach a large size, measuring 



220 POST-MORTEM EXAMINATIONS 

at times five or six inches in diameter. Metastases to other organs 
often occur, though other portions of the liver may escape. 

Other Tumors. — In addition to carcinomata and sarcomata, the 
liver is the seat of adenomata, adenocystomata, angiomata, fibromata, 
and aberrant adrenal tumors similar to those found in the kidney. The 
cavernous angiomata are usually small in size and, when found, are 
usually seen on the surface of the liver in elderly persons. They may 
be injected with colored material by means of any of the hepatic blood- 
vessels, and then form excellent microscopic specimens for future study. 
A cystic liver may be associated with a similar condition of the kidneys. 

Parasites and Infectious Diseases. — Psorospermice, Pentastomum 
denticidatum , Distomum hcematobium, Distomum lanceolatum, Dis- 
tomum liepaticum, and Echinococcus. Cases of primary tuberculosis 
of the liver have been reported, and syphilitic lesions are by no means 
rare. 

Pancreas. — Anomalies. — The tail of the pancreas is sometimes 
bifid, and peculiar divisions made by septa of connective tissue may 
occur in all parts of this organ. The pancreatic tissue by surrounding 
the duodenum may cause an intestinal stricture. Accessory pancreases 
have already been referred to in the technic of removing the gland 
from the abdominal cavity. 

Acute Pancreatitis. — This condition exhibits acute degenerative 
changes in the parenchymatous cells and an exudation into the inter- 
stitial tissue. It is often associated with cholelithiasis, and is usually 
hemorrhagic or gangrenous. In the lower animals pancreatitis may 
be produced experimentally by the injection of an artificial gastric 
juice, but it js impossible to foretell which form of the disease will 
result. Hemorrhagic Pancreatitis. — This variety of pancreatitis is 
usually associated with gastric or gastroduodenal dyspepsia, slight 
swelling of the epigastrium, and obstinate constipation. The pancreas 
is enlarged and infiltrated with blood. There is a cellular and fibrinous 
exudate present, with a necrosis of the parenchyma ; also disseminated 
necrotic foci are found in the omentum and peritoneum. This con- 
dition often ends in gangrenous pancreatitis, where the organ is en- 
larged, swollen, soft, friable, of a color varying from mottled red 
and gray to dark brown and black, and gives ofT a foul odor. The 
extension of the disease to the neighboring tissues may result in almost 
complete sequestration of the pancreas. In some cases it has been 
found that the organ has entirely disappeared, its place being taken 






DISEASES OF THE LIVER AND PANCREAS 2 2I 

by an abscess-cavity containing a foul-smelling mass, which may dis- 
charge through the intestine. Disseminated fat necrosis often follows. 
Gangrenous pancreatitis may be the result of a perforating inflam- 
mation of the gastro-intestinal or biliary tracts, arterial sclerosis, and 
hemorrhagic pancreatitis. Pancreatic Hemorrhage. — The pancreatic 
vessels may rupture from trauma, or the hemorrhage may accompany 
tumors, cysts, purpura, eclampsia, and acute infections. Apoplexy in 
this organ is seldom associated with arterial disease. Extensive fat 
necrosis now and again accompanies it. Opie considers that pancreatic 
hemorrhage and hemorrhagic pancreatitis represent a single patho- 
logic process. 

Chronic Interstitial Pancreatitis. — This disease is related to dia- 
betes mellitus, is secondary to morbid changes in the intestines, the 
bile-passages, and the liver, and is associated with arterial sclerosis, 
syphilis, tuberculosis, and abuse of alcohol. The islands of Langer- 
hans are frequently not affected. Chronic Pancreatitis. — In the inter- 
lobular form of this disease the gland is hard, dense, and nodular, with 
a granular surface. On section the tissue is compact and homogeneous, 
the loose areolar tissue being replaced by scar-like bands. The islands 
are unaltered, and the acini have atrophied nuclei and dilated lumina. 
Lymphoid cells are present in great numbers. In the interacinous 
variety the gland is tough and shows newly formed connective tissue 
in the lobules. The lesions are diffuse and irregular in distribution; 
in one place thickening of the connective tissue and of the network 
supporting the acini may occur, while elsewhere are found compact 
bands or small masses of stroma. Lobulation is observed, and at 
times is associated with general pigmentation. The change in either 
case may be only microscopic. Fatty infiltration may obscure both 
types. Chronic pancreatitis may be due to obstruction of the pan- 
creatic duct, to pancreatic or biliary calculi, to malignant growth com- 
pressing or invading the organ, to an ascending infection from the 
duodenum, to alterations of the. blood-vessels, to arterial sclerosis, to 
association with chronic tuberculosis of other organs, and at times to 
alcohol and to cirrhosis of the liver. It is very rarely due to syphilis. 

Congenital Syphilitic Pancreatitis. — In this form of the disease 
the organ is enlarged and firm. There is a diffuse interstitial prolifer- 
ation of the interlobular and interacinous tissue, first with atrophy and 
finally ending in destruction of the parenchymatous elements. The 
arteries are the seat of a syphilitic periarteritis and the adventitia is 



222 POST-MORTEM EXAMINATIONS 

infiltrated with lymphoid cells. Finally the capillary network around 
the acini disappears. The islands of Langerhans are not involved, but 
arc surrounded by newly formed stroma. 

/ lyaline Degeneration.— -This especially attacks the islands of Lan- 
gerhans, and is often found in cases of diabetes, destroying the islands 
and obstructing the vascular supply of a large portion of the paren- 
chyma. Hyalin is deposited between the capillaries and the parenchy- 
matous cells. The affected areas are larger and more numerous in the 
tail of the pancreas and may involve two-thirds of the tissue. Epithe- 
lial cells are found arranged about a lumen, particularly at the periphery 
of the altered tissue, and show that the acini are also affected. In the 
head and body of the gland the areas are smaller and fewer. 

Fat Necrosis. — This consists of small opaque white areas found 
in the fat around the pancreas, which are made up of necrotic fat-cells. 
In disseminated fat necrosis small foci are widely scattered in the fat 
of the abdomen. Large foci occur, especially in the fat of the omentum. 
Both a subperitoneal and a retroperitoneal fat necrosis indicate some 
grave alteration of the pancreas. These areas are frequently sur- 
rounded by a narrow hemorrhagic zone. While these lesions are 
usually limited to the fat in the abdominal cavities, they are found, 
as Hauseman has observed, in the subcutaneous fat corresponding in 
location to the reddish areas visible during life upon the overlying skin. 
They are probably caused by the action of the fat-splitting ferment 
upon living fat. 

Diabetes Mellitus. — A constitutional disease characterized by the 
continued secretion of large amounts of pale cloudy urine, of high 
specific gravity, containing glucose and, at times, acetone, diacetic acid, 
and beta-oxybutyric acid. It is, as a rule, associated with excessive 
hunger and thirst and sometimes with increase in fat, and at other 
times with progressive emaciation. It occurs most frequently in adult 
males, Hebrews being especially predisposed. It is due to some fail- 
ure properly to utilize certain carbohydrates in metabolism. There 
is a tendency to destructive changes in the tissues and to death from 
coma. It may be caused experimentally by ingesting phloridzin and 
by puncture of floor of fourth ventricle. Glycosuria is seen with exoph- 
thalmic goitre, certain neuroses, some diseases of the liver, cirrhosis, 
lesions of the pancreas, injuries to the nervous system, destruction of 
gray matter in the floor of the fourth ventricle, extirpation of cervical 
ganglion, pancreatic calculi, atrophy, carcinoma, necrosis, fatty degen- 



DISEASES OF THE LIVER AND PANCREAS 223 

eration, cysts, acute and rarely chronic interlobular pancreatitis. Some 
cases of the disease show an absolutely healthy pancreas, yet it occurs 
often with chronic interacinous pancreatitis. Diabetes is closely re- 
lated to destructive lesions of the islands of Langerhans, especially 
with hyaline changes and interacinous pancreatitis. In diabetes the 
number of islands may be diminished and the pancreas be nearly 
always atrophied. Arterial sclerosis accompanies many cases of dia- 
betes : also, acromegaly. It is occasionally associated with tabes. 
The cceliac ganglion is atrophic in this disease (Orth). Neuro- 
retinitis is very common, and there may be hemorrhages in the retina 
and opacities in the vitreous. The most usual change is a thickening 
and congestion of the membrane. The blood generally appears 
normal, but contains an increased amount of glycogen, and may 
be loaded with finely divided fat which floats on the surface in a 
cream-like layer. There may be lipaemic clots in the vessels. Fat 
embolism of the pulmonary vessels has been described. The myo- 
cardium is pale and soft; rarely it may be hypertrophied. Advanced 
fatty degeneration of the muscular fibres is the characteristic change 
in long-standing cases of diabetes. Croupous pneumonia and broncho- 
pneumonia, chronic interstitial pneumonia, and tuberculosis are com- 
mon complications ; many of them terminate in gangrene. The lung 
may soften (malacia) and, becoming mixed with stomach secretions 
post mortem, form the so-called pnenmomalacia acida. It has a sour 
but not a gangrenous odor. The spleen is usually small, pale, and soft, 
but may be enlarged and congested. Diffuse nephritis with fatty de- 
generation, and frequently glycogenic degeneration, most marked in 
the pyramids, may occur. Boils, carbuncles, onychia, eczema, and gan- 
grene of the extremities are common. The liver is usually enlarged, 
often congested, abnormally firm to the touch, and gives the glycogen 
reaction: fatty degeneration is common. Do not mistake diabetes 
mellitus for alkaptonuria; in the latter disease pigmentation of the 
cartilages or ochronosis may occur. 1 Some alkaptonuriacs do not show 
ochronosis, but thus far all the cases of ochronosis exhibit alkaptonuric 
changes in the urine. Established facts concerning diabetes : ( 1 ) Con- 
siderably more than one-half of all cases arc due to a destructive dis- 
ease of the pancreas. (2) When due to disease of the pancreas, injury 
to the islands is responsible for the disturbance of metabolism in the 

1 Osler, Lancet, January 2, 1904. j> 10. 



224 POST-MORTEM EXAMINATIONS 

carbohydrates. (3) Common lesions injuring the islands are chronic 
interacinous inflammation and hyaline degeneration. (4) Other le- 
sions of the pancreas do not attack the islands of Langerhans, but 
produce diabetes by destroying the interacinous islands along with the 
secreting parenchyma. (Opie.) According to the experiments of 
Sauerbeck 1 upon guinea-pigs, total extirpation of the pancreas or 
the tying of its secretory duct gives rise to atrophy of the islands of 
Langerhans and the subsequent development of diabetes. 

The Bremer-Williamson reaction of diabetic blood may be obtained 
a considerable time after death ; the procedure is as follows : Forty 
cubic millimetres of water are placed in a small, narrow test-tube ; to 
this are added twenty cubic millimetres of blood, one cubic millimetre 
of a one to six thousand aqueous solution of methylene blue, and forty 
cubic millimetres of liquor potassse. The test-tube is placed in boiling 
water for four minutes, at the end of which time, if the blood is dia- 
betic, the blue color will have disappeared and a dirty-green color will 
have taken its place. Williamson obtained the reaction in forty-three 
cases of diabetes tested and thinks it is due to an increase of glucose 
in the blood. The reaction is of special value in coma where urine can- 
not be obtained. 1 

Hcematochromatosis {Bronzed Diabetes). — This disease is due to 
a disturbance of iron metabolism. It affects various organs. Brown 
pigment is deposited within certain tissues and gives a microscopic 
pigmentation. Most of the glands are deep brown and their secreting 
cells are reddish-yellow or tinged with ochre-colored granules. The 
parenchymatous cells and Kupffer's cells of the liver contain pigment. 
A yellow fine pigment is seen in the smooth muscle-cells of the stomach, 
intestine, blood- and lymph-vessels, rarely in the urinary bladder, ureter, 
vas deferens, Glisson's capsule, or splenic trabecular This second pig- 
ment contains no iron. These symptoms associated with cirrhosis of 
the liver are called Recklinghausen's hemochromatosis. Pigmentation 
is seen also in the liver and spleen in cases of anaemia. 

1 Ergebnisse der allg. Path. u. path. Anat., 1904, eighth year, part II, p. 691. 

2 Brown, International Clinics, January, 1903, p, 266. 



CHAPTER XIII 

EXAMINATION OF THE SKULL AND BRAIN 

The body is placed in the supine position on the side of the table 
nearest the operator, with the head, elevated by a block placed under 
the neck and occiput, projecting slightly beyond the end of the table. 
If the cadaver be in a coffin or box, it may be drawn to the upper end 
thereof, the head being raised and placed upon a board laid across the 
top. the back supported by a head-rest, a block of ice, or any convenient 
bundle of rags or paper. Of the various forms of support employed, 
the Cornell head-rest (Fig. 45) is peculiarly well adapted for holding 
the head steady. 

Xote any anomaly in the size or shape of the head. ( See page 361. ) 
The scalp should be subjected to the same careful preliminary scrutiny 
for evidences of disease or injury, remote or recent, as the other parts 
of the body. It is then divided by an incision extending from one 
mastoid process to the other (Fig. 121), passing over the vertex when 
the hair is abundant and about midway between the vertex and the 
external occipital protuberance when it is thin. If the hair be long, 
it should be parted along the proposed line of incision, in order that 
as little of it as possible may be cut (Fig. 122). For the same reason 
and to guard against damage to the knife, the cutting edge of the 
scalpel or cartilage-knife should be directed from the skull when the 
scalp is being cut. When all the tissues overlying the skull have been 
separated, the scalp is reflected backward and forward by force, the 
calvarium being exposed from the occiput to or slightly beyond 
the frontal eminences. The eyes and nose should be protected by 
pledgets of cotton placed beneath the anterior flap. Care should be 
taken to avoid tearing the scalp at the extremities of the incision behind 
the ears, especially if the posterior incision with a large anterior flap 
be made. Indeed, it is for this reason that the incision is begun and 
ends behind and not in front of the ears, for a tear behind the ear 
would hardly be noticed, while one in front would cause considerable 
disfigurement. The scalp ma}- be so adherent \<> the cranium — a con 
dition more apt to occur in the posterior segment than in the anterior — 
te its removal by dissection with the knife or scraping with 
a chisel. Whatever instrument is used, guard against its slipping, lest 

15 225 



22 6 POST-MORTEM EXAMINATIONS 

injury be done to the operator or to the subject. Avoid undue traction 
of the scalp, which would cause it to present a baggy appearance when 
replaced. 

The skull should next be examined in detail. Fractures and other 
evidences of injury may now be revealed which could scarcely have 
been discovered in the preliminary examination. Note should be made 
of the presence of atrophy, hypertrophy, or softening of the bone, of 
premature or delayed synosteosis and supernumerary bones, of tumors, 
syphilitic or tuberculous abrasions or openings, marks of previous 
trephining, of asymmetry and abnormal coloration, the " greenish- 
yellow'' discoloration due to osteomyelitis or the " citron-yellow" due 
to tertiary syphilitic lesions, etc. (For cranial measurements and 
pathologic types of skull see Chapter XXIV.) 

There are two methods of removing the calvarium, — the angular, 
in which the skullcap is sawed in two intersecting planes meeting 
behind the ear, and the circular, in which the bone is divided in a single 
plane. The former method is usually to be preferred, as it permits 
more secure reposition of the skullcap, but the latter is easier of appli- 
cation and will, therefore, be considered first. 

The Circular Method. — The path of the saw, which may be 
marked with a pencil or the point of a knife, traverses a plane cutting 
the skull from half an inch to an inch above the glabella anteriorly, 
an inch or an inch and a half above the external auditory meatus 
laterally, and passing just above the inion posteriorly. This line will 
cross the temporal muscles obliquely, and they and their fascia should 
be divided with a knife instead of the saw, in order that their edges 
may be accurately approximated for suturing when the skullcap is 
replaced. 

Sawing the skull is no easy task; it may be greatly facilitated by 
the employment of an electric or dental engine. For this part of the 
operation it is a decided advantage to be ambidextrous. While the 
sawing is being done with one hand, the head must be steadied with 
the other, placed either on the vertex or on the face and protected 
by a towel, for the saw is liable to slip, especially when first applied. 
The scalp, especially of a female, should be protected from " sawdust" 
by wrapping towels about it. Proffered assistance should be declined, 
because, while it is natural to look out for one's own fingers, it is 
impossible effectively to guard another's. The reason I often give 
for not accepting aid is that " I am reasonably supposed to know 




Fig. I2t. — While the right ear is held back with the left hand an incision is started directly over the 
mastoid process. The remainder of the incision over the vertex will be made from within outward, thus 
avoiding dulling the knife and cutting the hair. 




FlG. 122.— After the initial incision has been made behind the ear, tin- hair may be parted when it is long, 
so as not to injure it when incising the sr;i]p. 




Fig. 123.— Method of sawing the skullcap. The temporal muscle has been cut through with a knife in the 
direction of the future sawing, and a pencil mark shows the posterior line along which to saw. The hand is 
protected with a towel. 




Fig. 124.— Angular method of removing the brain. The saw markings in each case pass close to the ear and 
meet an inch or so above it. The left hand is covered with a towel to protect it from injury. 




Fig. 125.— Method of breaking up the inner table with an old knife after sawing. (There are also 
various forms of chisels made especially for this purpose.) 




Fig. 126.— Method of drawing off the skullcap with a retractor after the sawing is completed. 




Ik.. 12 ■,. Appearance of the dura mater after removal of the calvarium, showing the superior longitudinal 
sinus and the meningeal vessels. 



EXAMINATION OF THE SKULL AND BRAIN 227 

where my hand is, but not where yours may be." The saw may be 
carried entirely through the bone or, better, only to the inner table, 
this being divided with chisel and hammer. In no case, however, 
where it is suspected that the skull may have been fractured should 
the latter procedure be adopted, as the force of the blow required 
might be sufficient to split the bone. While a post-mortem fracture 
may be recognized by the absence of extravasated blood, the enlarge- 
ment of a pre-existing fracture is more difficult to differentiate. A 
receptacle should be placed beneath the head to catch the cerebro- 
spinal fluid and the blood that escape when the skullcap is removed 
and the meninges are opened, and care must be taken to prevent spat- 
tering. The calvarium is loosened by twisting a chisel or the sharp end 
of a hammer in the kerf, and removed with a blunt hook. If instead 
of an instrument the fingers be used for the purpose, they must be well 
protected, as they are liable to slip and be abraded by the sharp edges 
of the bone. Traction should be made steadily and not in jerks, 
lest from a sudden giving way the calvarium be damaged by falling 
on the floor or surrounding objects be soiled by the spattering of 
blood or other fluid. When, as is sometimes the case, the calvarium 
does not readily yield to traction applied in front, it may often be 
easily detached by inserting the hook posteriorly. If the dura be 
adherent, as not infrequently happens in cases of chronic alcoholism, 
old injuries, or sunstroke, it may be loosened with a blunt instrument, 
or it may be divided along its margin with a pair of blunt-pointed 
scissors or a curved, probe-pointed bistoury cutting from within out- 
ward, the falx cerebri being incised close to the corpus callosum. In 
children under seven years of age this must always be done, as up to 
this time of life the dura is normally adherent to the osseous structures 
of the skull. 

The Angular Method. — In this method the skull is sawed in 
two planes which by their intersection form an obtuse angle at a point 
a little below and slightly posterior to the apex of the ear. Always 
try to saw above the line of the hair in front. Although this makes 
the anterior fossa deeper and consequently the removal of the brain 
more difficult, it obviates the ugly ridge on the brow so liable to be 
made by the inexperienced. It is necessary too that the angles be well 
sawed through and carefully broken, because if spicules of bone remain 
the brain may be caught and injured during its removal. (For this 
method of opening see Figs. 123 to 126 inclusive.) 



22 8 POST-MORTEM EXAMINATIONS 

In the French method of opening the adult skull with a hammer, 1 
the anterior and posterior flaps are made in the usual manner. A line 
one centimetre above the soft tissue is drawn around the skull with a 
soft pencil or with ink, the temporal muscles being cut through with a 
knife; by means of blows with the hammer the skull is then fractured 
along this line. The sound tells you when the bone is fractured and 
warns you to proceed to a new place. (Fig. 127.) This method is 




(After Letulle.) 



much employed in France, and in the hands of experienced operators 
gives good results, though it is most difficult of performing in the re- 
gion of the exterior occipital protuberance. It must not be used in 
children, in cases of fractures, bone lesions, etc. The dura is opened 
along the circular incision, or, more frequently, crucial incisions are 
made on either side of the longitudinal sinus and each side is incised 
by a perpendicular cut running from the vertex down to the upper mar- 
gin of the bone. The four pieces are then turned down and the falx 
cerebri is cut anteriorly just behind the crista galli and with a portion 

1 J. Dejerine, Anatomie des centres nerveux, 1895, p. 13. 



EXAMINATION OF THE SKULL AND BRAIN 



229 



of dura on each side of the longitudinal sinus pulled backward. It 
will be seen that the dura mater thus covers the sawed portions of 
the bones (Fig. 128) and affords a protection to the hands in the 
subsequent removal of the brain. Aseptic compresses may also be 
used for a similar purpose. 

The thickness of the skull is next noted. It varies much, being 
usually greater in negroes and, at times, in syphilitic subjects. It 
also varies in different parts of the same skull, being thinnest in the 
temporal region and thickest at the occiput, and is often unequal 




Fig. 128. — French method of opening the dura. (After Letulle.) 



in corresponding points of the opposite sides. The diploe may be 
entirely absent in some places, in which case the bone-dust will lack 
the reddish color commonly observed in recently sawed bone. The 
skull is usually from two to six millimetres thick. In rare cases the 
frontal sinus may extend high up and be of unusual thickness; in one 
of my subjects it measured half an inch across at the top after removal 
of the calvarium in the usual manner. Note the relations of the 
external table, internal table, and diploe. Pay especial attention to 
the amount of blood in the latter; if abundant, suspect fracture. At 



230 POST-MORTEM EXAMINATIONS 

times it Is entirely bloodless. The skullcap should be held up to the 
light so that any inequality in its thickness may be perceived. The 
Pacchionian granulations often give rise to small nodular depressions 
in the inner table, which are of course perfectly normal and should 
not be mistaken for pressure atrophy. They sometimes cause perfora- 
tion of the bone, or permit of the passage of an external infection into 
the interior of the skull. 

The grooves of the middle meningeal artery must be looked for 
on each side. In one of my cases of acromegaly the inner table resem- 
bled worm-eaten wood; the bone was soft and pliable and offered no 
resistance to the saw. It is necessary to be familiar with the normal 
yellowish -gray color of the inner table in order that changes in it may 
be readily detected. Whenever blood is found between the inner table 
and the dura, careful search must be made not only in its vicinity 
but also on the opposite side for a fracture by contrecoup. In the exam ■ 
ination of the dura mater note its thickness, the degree of distention, 
its color, which is normally gray and never very red, and the amount of 
blood contained within it. As all liquid naturally gravitates down- 
ward, those portions of the dura which cover the most dependent parts 
will be most distended, unless, as often happens, an injury of this mem- 
brane has allowed the fluid to escape. 

The arteries lie between the two veins. The larger arteries usually 
contain more blood than the veins. The dura is supplied with but 
few capillaries and these rarely become inflamed. 

In the examination of the outer surface of the dura mater (Fig. 
129) note alterations in color and gloss. The latter is often lost in 
consequence of tumors, hemorrhage, hydrops, abscess, and other con- 
ditions that cause increase of intracranial pressure. Search for hemor- 
rhages (which at times are profuse and depress the brain) and their 
points of origin, Pacchionian bodies (which must not be mistaken for 
tubercles), bulging tumors, and external pachymeningitis (ossified, 
purulent, syphilitic, or tuberculous), etc. The degree of tension due 
to fluid, etc., may be determined by puncturing or by pinching up the 
dura. 

The brain may be exposed, but not dissected, before the heart is 
incised, as the quantity of blood in the cerebrum may be modified by 
venous oozing during the examination of the thorax. If the brain 
is to be injected, it is best not to remove the dura, as by its detachment 
usually some of the veins entering the longitudinal sinus are torn, and 




FlG. i.;o. — Appearance of the brain after removal of the dura, which has been left attached at its 
posterior extremity. 




Fig. 131.— Method of removing the brain after it is severed from the body. 




Fig. 132. — Dissection of the brain ; commencement of initial incision. 




'1 oi initial in< ision. 




Fig. 134.— Exposure of the central portions of the brain. 




FlC. 135.— Method of removing the cerebellar lobes from the pons Varolii 
and the medulla oblongata. 



EXAMINATION OF THE SKULL AND BRAIN 231 

this permits the escape of the injecting fluid when under pressure. It 
has been shown that this operation can be performed without external 
disfigurement while the brain is in situ by forcing the fluid through a 
cannula introduced by way of the nostrils or the orbits. 

The longitudinal sinus is opened throughout its entire length with 
a pair of probe-pointed scissors, and the condition and quantity of the 
contained blood are noted. 

The dura is divided parallel with and slightly above the sawed edge 
of the skull, with a pair of blunt-pointed scissors, which may be intro- 
duced through a chance nick made by the saw or through an opening 
made with a knife for the purpose. The incision is carried completely 
around the skull except at the poles of its anteroposterior diameter, 
where it is necessary to sever the falx cerebri. The arachnoid surface 
of the two lateral flaps of the dura ma}- be examined by reflecting them 
to one side. The character of the blood in the membranes of the 
brain and in its cortex, the fluid in the subarachnoid space, the charac- 
ter of the sulci and convolutions, and the presence of lymph are all to 
be noted. 

To detach the falx grasp both folds of the frontal dura with the 
left hand, and with the right insinuate the blade of a knife along the 
outer face of the left fold of the dura to its attachment to the ethmoid 
bone. This is severed by turning the cutting edge of the blade inward 
towards the falx and detaching it along the line of its insertion from 
before backward, as near the crista galli as possible without injury 
to the olfactory bulbs. As the knife reaches to the anterior genu of the 
corpus callosum, the index-finger may be gently introduced into the 
longitudinal fissure so that a view may be had of the portion to be cut. 
It is no unusual thing to leave behind a thin strip of the dura just 
above the corpus callosum, a mistake which may cause annoyance to 
the operator or injury to the brain during its removal. 

The dura may now be drawn backward and cut off posteriorly or 
left in situ in order to protect the hands of the operator and the brain 
in its removal (Fig. 130J. The portion of the pia mater dipping down 
to the genu and splenium of the corpus callosum may be detached with 
forceps, and that overlying the surface of the cerebrum with the fingers. 
The handling of this delicate membrane can be greatly facilitated by 
allowing a stream of water to flow gently over it during its removal. 
The pia is colorless when normal, but may be gray or grayish white 
when thickened, yellow when pus is present, or red from hyperemia 
or hemorrhage. 



232 



POST-MORTEM EXAMINATIONS 



The anterior extremities of the frontal lobes are gently raised with 
the tips of the fingers of the left hand, and any remaining shreds of 
dura are severed to prevent injury to the cerebral tissue in the frontal 
region or corpus callosum. With the handle of a scalpel the olfactory 
bulbs are now shelled from the grooves in the cribriform plate of the 
ethmoid bone in which they lie, and the entire brain is gently turned 
outward while supported by the left hand. The various nerves and 
vessels are divided, as near as possible to their respective foramina, 
with a sharp, narrow-pointed scalpel, always cutting towards the bone. 
The ophthalmic artery and optic nerve are now severed close to the 
optic foramen, first on one side then on the other. Next the dura en- 
closing the pituitary body is cut with a sharp knife near to the bone 
(sella turcica) at all points except posteriorly near the infundibulum, 
great care being taken not to injure the delicate hypophysis, which then 
may be shelled out and the remaining portion of the dura behind be 
excised with scissors. The internal carotids are cut long, especially if 
the brain is to be injected. Next cut the common motor oculi, the tri- 
geminal, external motor oculi, facial, auditory, hypoglossal, glosso- 
pharyngeal, pneumogastric, and as the temporosphenoidal lobe leaves 
the middle fossa of the skull, the tentorium cerebelli is divided with 
blunt-pointed scissors, or a knife with a broad flat back made especially 
for this purpose, along the superior border of the petrous portion of the 
temporal bone, preferably passing from the median line towards the 
sides. In making this incision care must be taken not to injure the 
cerebellum. 

The brain mass being now supported on the left hand, cut the cord 
as low down as possible by a transverse incision. Pick's myelotome 
is a very convenient instrument for this purpose. Orth thrusts the knife 
through the centre of the cord and severs first one side and then the 
other. Any attachments of the spinal cord, medulla, and vertebral 
arteries can readily be loosened by introducing the forefinger into the 
cavity of the spinal column and through the foramen magnum. Of 
course, if the cord has already been removed, it remains only to cut the 
vertebral vessels. 

The brain is now entirely free, but the cerebellum still remains in 
the posterior fossa, from which it is best removed by holding it firmly 
to the cerebrum with the fingers of the right hand and turning the 
brain first to one side and then to the other (Fig. 131). The brain 
with its pia and arachnoid still attached is now weighed. A towel pre- 



EXAMINATION OF THE SKULL AND BRAIN 233 

viously rolled up into the form of a turban makes an excellent tempo- 
rary resting-place for the inverted brain. 

During this entire procedure, which has taken longer to describe 
than it does to perform, the secant has been searching the exposed parts 
for any lesions or abnormalities, as their presence may modify subse- 
quent processes. 

Examine the external surface of the brain, the adherence of the 
pia-arachnoid being tested in several places, not forgetting the fourth 
ventricle, the circle of Willis, and the course of the middle cerebral 
artery lying in the fissure of Sylvius. With the latter the island of 
Reil and the retroinsular convolutions are also exposed. 

Quick, but not Accurate, Methods. — Some operators do not even 
take the trouble to remove the brain from the skull, but merely make 
a number of transverse incisions across the cerebral structures. This 
method is only mentioned to be condemned, though it may diagnose 
a hemorrhage, a tumor, or an abscess. 

In the coroner's work it is often necessary to make a diagnosis 
between heart-disease and apoplexy, when, because of baldness of the 
individual or for lack of time, it is impracticable to open the head. In 
such cases I have found it feasible to trephine just above the ear and 
from this point tap the ventricles and other situations liable to be the 
seat of hemorrhage, using an instrument resembling an apple-corer to 
remove brain substance for examination, though enough clotted blood 
may be brought out attached to a long thin brain-knife passed into 
the places where hemorrhage usually occurs — i.e., the ventricles and 
the cerebellar lobes — for the purpose of establishing a probable diag- 
nosis. 

Examination of the Base of the Skull. — The base of the 
skull and its sinuses are next to be examined. Study the dura at its 
base for ( 1) inflammation resulting from fracture or caries, (2) tuber- 
cles, (3) gummata, (4) thrombosis of lateral sinus, (5) pachymenin- 
gitis and leptomeningitis, and (6) tumors. A fracture may be hid by 
the dura, but its situation will usually be shown by the presence of hem- 
orrhage. The dura must be stripped off, though tin's often consumes 
considerable time, so that the surface of the bone may be exposed. 
Unless this is done, a linear fracture — one near the foramen magnum, 
for example — might easily be overlooked. Special examinations should 
now be made of the orbit, internal ear, and nasopharyngeal cavities. 



234 POST-MORTEM EXAMINATIONS 

INTERNAL EXAMINATION OF THE BRAIN. 

The brain may be sectioned either immediately upon its removal or 
after first being hardened, each method having its advantages. If an 
immediate diagnosis is required or colleagues are present to give 
unusual interest to a discussion of the findings, the sectioning will 
probably he done at once. If any hemorrhagic lesion is suspected, 
it is more conspicuous in the recent state, and a wholly unexpected 
bacteriologic investigation might be demanded by the revelations of 
the incisions. If none of these considerations prevail, the brain is 
hardened in a medium which will not interfere with any microscopic 
work that may be desired after the sectioning. Since hardening in 
certain fluids is necessary for certain stains and entirely precludes 
others, we must first of all decide what staining methods will be used 
before a choice of hardening fluids can be made. A two and one-half 
per cent, solution of bichromate of potassium or Miiller's fluid will 
develop color contrasts between the white and gray matter and furnish 
material for Weigert and Golgi work, but the later methods for gan- 
glion cells and neuroglia are precluded. Formalin is suitable for all 
special staining methods, including Nissl's, though the best results 
are obtained when the tissues are hardened in alcohol. 

The brain may be hardened entire in a ten per cent, solution of 
f< >rmalin in a week or ten days and be suited for general topographic 
work. For finer histologic methods the parts should be serially in- 
cised, the sections being not more than three millimetres thick and 
remaining in situ, or, if the material to be studied is not superficial, 
the brain may be incised according to the methods herein to be given 
and then hardened. The advantages of hardening the brain in most 
pathologic cases are so obvious that they do not require mention. 
Jt should always be done unless contra-indicated, and when the fresh 
brain is sectioned and examined, the incisions should be so made that 
all the segments will fold together like the leaves of a book, — unin- 
jured, undisturbed in their structural relationship, and fit for the most 
exhaustive microscopical examination. 

Whether the brain is sectioned first or after hardening, the choice 
of a method will be somewhat determined by the situation of the 
lesion and the desire to preserve intact all its structural relations. 
Morbid changes in the cortex which we might wish to trace down 
through the internal capsule would be studied only with the greatest 



EXAMINATION OF THE SKULL AND BRAIN 235 

difficulty after sectioning by Meynert's method, whereas if the lesions 
were bulbar or situated anywhere in the brain-axis this method would 
be very advantageous, since it permits of examining the whole of the 
brain-axis by serial sections. 

The centrum ovale is well studied by Pitres's method, but future 
microscopic investigation is impossible. The same is true of Noth- 
nagel's method, and to examine lesions of the internal capsule we must 
have horizontal sections. For exposing suspected or unsuspected 
lesions, for gaining a good idea of the general condition of the brain, 
and for ease and rapidity of routine work, probably no method is more 
useful than that of Virchow. Unfortunately, it does not favor micro- 
scopic examination and therefore is rather sweepingly condemned by 
some authors. 

Dejerine makes a special effort so to section the brain that it may 
be sufficiently exposed without in any way interfering with future 
investigation. 

Yirchow's Method. — A long, sharp knife should be used in the 
dissection, which should be kept clean and moist by frequent washing, 
so that the cut surfaces will be even and smooth. A dull knife tears the 
brain substance more or less, thus distorting the delicate structures. 
Virchow insisted strongly upon the necessity of a long, clean, smooth 
incision being made at one stroke, and said that he would rather have 
a wrong incision rightly made than a right incision wrongly per- 
formed. 

The brain is placed on its base with its occipital lobe towards the 
operator. Laying the left hand upon the left hemisphere, with the 
thumb in the longitudinal fissure and the fingers upon the convexity, 
raise this hemisphere slightly and pull it away from the median line 
so as to expose the corpus callosum. Insert the point of a thin nar- 
row knife into the roof of the lateral ventricle, which lies immediately 
below the corpus callosum, well forward and two or three millimetres 
externally to the median raphe of the corpus callosum ( Fig. 132). 
Make a concave incision — concavity directed outward — through the 
roof back to the posterior corn 11. being careful not to injure the floor 
of the lateral ventricle. Xote the character and quantity of fluid 
present, which normally is perfectly clear and about three cubic centi- 
metres in amount. Connect the two extremities of the first incision by 
a second and third incision meeting at an angle of 45 degrees just 
outside the basal ganglia. \n this manner the greater portion of 



236 POST-MOKTKM KXAMINATIONS 

the cerebral cortex on the left side will be removed away from the 
basal ganglia for future sectioning (Fig. 133). The right hemisphere 
may be turned half around and sectioned in the same way. 

The knife is then introduced into the foramen of Monro and the 
anterior fornix is brought forward, exposing the vela interposita and 
the choroid plexuses, which with the body of the fornix are carried 
back, thus exposing the third ventricle (Fig. 134). Then examine 
the corpus fimbriatum, the lyra, the anterior, posterior, and middle 
commissures, the corpora quadrigemina, the pineal body, and the 
commencement and lumen of the iter a tertio ad quartum ventriculum. 
The pineal gland is often infiltrated with salts, as may readily be deter- 
mined after sectioning by rubbing a small portion of it between the 
thumb and index-finger. If it be desired to examine the fifth ventricle, 
an incision is made directly in the median line into the septum lucidum, 
parallel to the corpus callosum, the anterior fornix being elevated by 
the left hand and thus put on a stretch. 

The crura are then severed by transverse incisions joining at about 
a right angle in the median line. The cerebellum, the medulla oblon- 
gata, and the pons Varolii are next to be removed. This may be done 
at the start, if preferred; reversing the order here given as to the other 
parts of the brain. After examining for dilated veins, tumors, and 
cysticerci, transverse incisions are made in the cerebellum on one side 
through the centre of the arbor vitse, and then on the other side. The 
cerebellum may, however, be removed before these incisions are made 
by severing the medulla oblongata and the pons Varolii and dividing 
the cerebellar hemispheres in the median line into two parts. The pons, 
the medulla, and the commencement of the spinal cord may now be 
cut transversely by incisions one-fourth to three-eighths of an inch 
apart, and all pathologic changes carefully noted, but these portions 
are preferably hardened previous to examination, which is best accom- 
plished by the preparation of serial sections. (Figs. 135 to 139 inclu- 
sive.) 

Both Nauwerck and Orth, before making transverse sections of 
the pons and medulla, fold the sections of the brain together as you 
would the pages of a book in order that it may be turned. Then, 
pushing the fingers of the left hand under the pons and medulla, the 
transverse cuts may be made. In case of tumors or metastatic condi- 
tions simpler methods may be used; thus, only one longitudinal or 
one tran s verse section may be made through the diseased as well as 
the healthy tissue, while the arachnoid is left intact. 




Fig. 137. -Method of sectioning the cerebellum. 




FIG. [38. — The whole brain after it has been sectioned. 




Descending fornix 



Descending fornix 



Fig. 159.— Section of the brain. The lines and arrows show the position and direction of the various 
incisions. (After Nauwerck.) 




si ganglia, with cerebellum, pons Varolii, and medulla oblongata atta< bed, in Meyn< it's 
method of dissecting the brain. The twelve I ranial nerves arc Shown. C. cerebellum ; /". fl<>< 1 ttlus : 'A 
medu - :; t. L. t temporal lobe ; F.L., frontal lobe; P, peduncles; C.a., corpora 

albica . ■ ,,-ai commissura; R.I, c. retroinsular convolution; 0. Coptu commissura; /'..v., 

poster: 1 i torynerve; /.insula. (After Dejerine.) 




Fig. 141.— Sectioning of the brain. A B, incision practised by Flechsig; CD, that of Bris- 
saud; E F, that of Dejerine. The hemisphere to be incised is placed on its external surface, 
the occipital lobe towards the operator in case of the left hemisphere, and the frontal lobe for 
the right hemisphere. (After Dejerine.) 




FlG. 142.— Incisions made by Dejerine in a case of cortical lesion previous to hardening. 



EXAMINATION OF THE SKULL AND BRAIN _-- 

Meynert's Method, slightly modified by Blackburn. — The 
brain is placed with its base upward and the cerebellar end towards 
the operator. The cerebellum is elevated and the pia mater cut through 
above the corpora quadrigemina, around the crura, and along the 
inner margins of the temporal lobes until the middle cerebral arteries 
are reached. The Sylvian fissures are opened to their entire extent, 
the opercula are raised, and the insular lobes exposed to their limiting 
furrows. 

The apices of the temporal lobes are now elevated, and, with the 
knife held nearly horizontal, their junction with the base is cut through 
until the anterior extremities of the descending cornua are opened. 
The knife is inserted in the descending horn, and the incision is carried 
backward as far as the posterior angle of the insula, or even some 
distance beyond it, severing some of the convolutions at the posterior 
extremity of the Sylvian fissure. 

The next incision is made to separate the basal piece from the 
posterior extremities of the frontal lobes. It connects the anterior 
boundaries of the islands and opens the anterior horns of the ven- 
tricles. The incision may be a slightly curved, transverse one, con- 
necting the anterior border of the islands; or, by a little care and a 
double crescentic cut, the exact boundaries of the convolutions may be 
followed. 

The cerebellum is now raised, the knife entered at the posterior 
angle of the island, and the incision carried along the outer limiting 
furrow until it meets the cut previously made through the anterior 
border. Care must be taken to keep the knife in the angle between the 
roof of the ventricle and the basal ganglia, to avoid injuring the latter. 
The basal piece is now lifted until the anterior crura of the fornix and 
the septum lucidum may be severed, and the basal section thereby 
completed. 

The basal piece thus separated includes the island of Reil, the basal 
ganglia, the crura, pons, medulla, and cerebellum. (Fig. T4°-) 

Pitres's Method. — The lateral ventricles are exposed as in Vir- 
chow's method. The hemisphere lies on its under surface and a series 
: x transverse vertical sections are made parallel to the fissure of 
Rolando. These are called the prefrontal, pediculo-frontal, frontal, 
parietal, pediculo-parietal, and occipital. Titre's method is very use- 
ful for localizing lesions in the centrum ovale, but not at all adapted 
to studying the internal capsule nor for subsequent microscopic work. 
The same is true of the closely similar method of Nothnagel. Flech 



238 POST-MORTEM EXAMINATIONS 

sig^s, Brissaud's, or Dejerine's primary incision may be made, and after 
studying the cut surfaces the two parts are replaced and Pitres's cuts 
added thereto. 

The next method to be described, that of Dejerine, gives the best 
results of any of the methods now in vogue. 

Method of Dejerine. 1 — The brain is examined upon all its sur- 
faces to see if there be any cortical lesion. The inferior surfaces of the 
crura are carefully inspected for secondary degenerations. The cere- 
brum is separated from the cerebellum by sectioning the pons hori- 
zontally in a plane directly parallel with the inferior surface of the 
hemispheres and passing just above the great root of the trifacial. Fig. 
141 shows the direction of the incisions adopted for this purpose by 
Flechsig, Brissaud, and Dejerine. This divides the brain into two 
portions. The upper one contains the two hemispheres, the cerebral 
peduncles, and the superior portion of the pons, while the corpora 
quadrigemina is preserved intact by the obliquity of the incision. The 
lower portion contains the rest of the pons, the cerebellum, and the 
medulla. The surfaces of the section through the pons are carefully 
examined for degenerations in the pyramidal tracts, and the two hemi- 
spheres are separated after determining in which one the lesion is situ- 
ated, which is often decided by the appearance of degenerations in the 
cut surfaces of the pons. While Dejerine regards this as important to 
determine, because the corpus callosum should be sectioned as closely 
as possible to the normal hemispheres, and the incision should not pass 
through the interpeduncular space but encroach at least a centimetre 
upon the sound peduncle and corresponding portion of the pons, other 
neuropathologists object to this mode of procedure as being apt to cause 
disfigurement of the parts. 

The method of examining the hemispheres is determined by the 
situation of the lesion, — whether it is central or cortical. If central 
the only degenerations that are of importance are those of the tracts 
of the internal capsule and in the region of the tegmentum (dorsal 
portion of the crus cerebri). Divide each hemisphere by a horizontal 
incision passing through the superior third of the optic thalamus, 
harden, prepare a drawing of the part, and section with a microtome. 

If the lesion is cortical the brain is sectioned by (1) a vertical 
transverse incision (Fig. 142, CD) passing just posterior to the sple- 

1 Anatomic des centres nerveux, 1895, p. 22. 



EXAMINATION OF THE SKULL \XP BRAIN 239 

nium of the corpus callosum, and (2) a vertical transverse incision 
(A B) just anterior to the knee of the corpus callosum. In this way 
the hemisphere is divided into three segments. The posterior segment 
is composed of the occipital lobe and part of the parietal. The anterior 
is the forepart of the frontal lobe. The central is the largest and con- 
tains the regions adjacent to the fissure of Rolando, the middle portion 
of the temporal convolutions, the posterior portion of the frontal con- 
volutions, the basal ganglia, the cerebral peduncle, and the correspond- 
ing part of the pons. The anterior and posterior segments are hardened 
as they are, and the central segment also if the cortical lesion is exten- 
sive and deep so that the fluid can penetrate easily; if not, a horizontal 
section (E F) is made through the superior third of the optic thalamus. 
In either event the pieces are hardened and cut with a microtome, pre- 
ferably of the Gudden type. The anterior and posterior segments are 
cut vertically transverse and numbered. The central segment or seg- 
ments are incised horizontally. In this way not only can a cortical 
lesion be localized with great precision, but traces of degenerating 
fibres may be studied throughout their whole extent, which is riot 
practicable by any other method. 

Hamilton's Method. — Hamilton injects the vessels of the brain 1 
as follows : The brain is freed from the dura, but not from the pia 
and arachnoid, weighed, and injected through the vessels at the base 
with Midler's fluid or any other hardening agent desired. It is well to 
have a round stoneware jar with a lid of sufficient size, three fair-sized 
cannulas, several feet of good rubber tubing of a caliber to receive the 
ends of the cannulas, and a three-tubed " distributer." A piece of the 
rubber tubing about eighteen inches long having been firmly tied on 
one end of a cannula, its other end is tied into an artery, — viz., one 
into each carotid and one into one of the vertebrals, the opposite ver 
tebral being securely ligated. The brain, with its attached tubes, is 
now placed in the jar. which is partly filled with the hardening fluid 
The weight of the cannulas and tubes is taken off the vessels by sus- 
pending the tubes over the erlge of the jar. Tie the other ends of the 
rubber tubes to the three arms of the distributer, and connect the com 
mon tube with the stopcock of a tank filled with the preservative fluid, 
which can be conveniently raised or lowered at will, and is now placed 
about four feet above the brain in the jar. 



1 Text-book of Pathology, 1889, vol. i. p. 56. 



2-jO 



POST-MORTEM EXAMINATIONS 



When certain that all attachments are secure, the stopcock is grad- 
ually opened, allowing the tubes to become filled and the fluid to per- 
colate slowly through the brain. Care should be taken that the can- 
nulas do not bend the arteries short upon themselves, thus occluding 
their lumina. The first fluid which passes through will be mixed with 
blood and should not be used again, but when it has become clear 
it may be used over and over. It usually runs through very quickly, 
and the tank should be refilled at least every day for the first week, 
and oftener if convenient. The brain should always be in an excess 
of the fluid and a vessel provided for the overflow. For refilling the 
tank it is best to draw some of the liquid out of the jar with a siphon, 
which will not disturb the brain or the position of the cannulas. 

A week or two will suffice in urgent cases, but the longer the brain 
remains in the fluid the better will be the hardening. Some of my 
most beautiful specimens are those which were kept in Miiller's fluid 
for five or six months. Haste and thoroughness are incompatible in 
this process. No padding should be used to keep the organ in position, 
the best and surest agent for this purpose being a plentiful excess of the 
liquid and an occasional change in its position. 

If it seems unnecessary to inject the vessels, the following method 
may more easily be carried out and gives most excellent results. An 
open jar, bucket, or wash-basin is one-quarter filled with absorbent 
cotton, and Miiller's fluid — to which one per cent, of formalin may be 
added with great benefit — is poured in until the vessel is about half full. 
The brain, after being weighed, is carefully placed in the centre of 
the vessel and more fluid is added until the organ is well covered, 
when it is placed in a refrigerator. If this be done, even though the 
arteries have not been injected nor any incision made into the ven- 
tricles, there is no danger that the brain will decompose, even in sum- 
mer. On the next day the position of the brain is altered and the fluid 
changed. The renewal of the fluid can best be accomplished with a 
siphon, only a part of it being removed at one time. 

The fluid is changed again on the third day, then every other day 
for three times, twice a week for the next three weeks, and once a 
week for the final three weeks. Remember that the jar is uncovered, 
and this allows of the evaporation of the fluid and possible spoiling 
. of the specimen. The brain can then be thoroughly washed and put in 
80 per cent, alcohol, or the Miiller's fluid can after the fifth or sixth 
week be diluted with one-fifth alcohol, then with one-quarter, one- 



EXAMINATION OF THE SKULL AND BRAIN 24 1 

third, one-half, and finally three-quarters alcohol, where the brain can 
be kept for several months until it is transferred to the alcohol of 80 
per cent, strength. Instead of Midler's fluid a 2.5 per cent, solution of 
bichromate of potassium may be employed. It is important to remem- 
ber that nervous tissue preserved for the purpose of study by the Nissl 
method should not be placed in Miiller's fluid, but in alcohol or for- 
malin. About two thousand cubic centimetres of a 10 per cent, forma- 
lin solution are used and changed every third day. The solution should 
be kept in a tightly closed jar to prevent the escape of the formalin. 

Giagomini's Method. 1 — This is well adapted for the macroscopic 
study of the brain, but, on account of the zinc chlorid used, the tissue 
is rendered unfit for microscopic work. If the specimen is a brain 
tumor, a small portion of it may be placed in a hardening fluid for 
microscopic study and the remainder then treated by this process. 

The brain, in as fresh a state as possible, is put into the Liquor 
zinci chloridi (U. S. P.). It will be found to float at first and should 
be turned several times the first day. On the second day the pia and 
arachnoid, which until now have been useful in keeping the brain 
intact, are removed while the organ is under water or floating in the 
fluid; if allowed to remain longer, they become so adherent to the 
cortex as to be separated with difficulty and more or less damage to 
the cortical substance. The brain is left in the fluid for from six to 
ten days, then removed, well washed with water, and put in 95 per 
cent, alcohol for ten days or two weeks and next in glyeerin for another 
ten days or more. After this it is placed in absorbent cotton and 
exposed to the air in a dark place free from dust. Any exudation 
should be carefully removed, and when no more appears (which may 
be in from several weeks to as many months) the surface is to be 
well coated with the best mastic varnish applied with a soft camel's- 
hair brush. To prevent flattening of the surface upon which it rests, 
it must be well packed in absorbent cotton and its position frequently 
changed. 

Kaiserlixg Method. — See page 343 for the preparation of brains 
with the object of preserving their natural coloration. 

1 Gior. di r. Accad. di med. di Torino, 1883. 



16 



CHAPTER XIV 

THE SPINAL CANAL AND CORD 

The spinal cord may be removed either anteriorly or posteriorly, — 
i.e. j by excising the bodies of the vertebrae through the thorax and 
abdomen freed from their viscera or by severing the laminae and spinous 
processes of the vertebrae through an incision posteriorly. The latter 
route is decidedly the more convenient and is used whenever possible. 
Generally it is best to remove the cord before the abdomen is opened, 
this being a much cleaner operation, an important factor in private 
practice. 

The cadaver is placed prone upon the table close to the side at 
which the operator stands, with the head hanging over the end or, 
better, with a block under the chest and neck and, if desired, one 
under the lumbar region. Beginning at the external occipital pro- 
tuberance, an incision is carried along the spinous processes to below 
the fourth lumbar vertebra, dividing all the tissues down to the bone. 
(Figs. 143, A B, and 144.) The incision is made low in order to 
allow for room for future manipulations, as the tissues here are thick 
and the future sawing is to be done in a hollow, as it were. The super- 
ficial and deep structures are then dissected from the bones, exposing 
the vertebral groove on either side of the spinous processes. Or, after 
incising the skin over the spinous processes, insert the knife, with its 
back down, at the lower end of the incision and cut upward along the 
column, keeping the blade pressed against the spinous processes. In 
this way the fibrous attachments are cut close and the vertebral groove 
is clean and free from troublesome soft tissues. The soft parts should 
be very thoroughly removed, as they would interfere considerably with 
the subsequent sawing. This can be quite well done by scraping with 
a chisel or an old knife. 

In cases of luxation, fracture, Pott's disease, etc., it may be 
desirable to remove portions of the vertebral column en masse. This 
can readily be done by the proper use of a saw after severing the inter- 
vertebral cartilages above and below the lesion. The space is then 
filled by inserting a stick and pouring plaster upon it. 

The canal is easily opened with Luer's rhachiotome, an adjustable, 
242 




Fk;. 144. — Position of the body in removal of the spinal cord. The primary incision is being made. 




Fk,. 145.— Removal of spinal cord. The primary incision has been made and the vertebral column freed 
from muscle, fascia, etc. The angle at which the saw should be held is well shown. 




% ° 
















c c s 



<u o ? 

I «2 



£ S E 
R_§ ° 



THE SPINAL CAXAL AND CORD 



243 



double-bladed saw devised for die purpose (Fig. 25) . It does the work 
more quickly, but has the serious fault that it is liable to become im- 
pacted and injure the cord in its release. The same object may be 
accomplished with a single-bladed saw having' curved ends (Fig. 21). 
The lamina should be sawed close to the transverse process, with the 
saw teeth held away from the spine at an angle of about thirty degrees 
(Fig. 145). Unless this direction is taken there is some danger that 
the canal will be missed or that the blade may enter it and the cord 
be injured. Orth calls attention to the fact that one can tell when 
sufficient sawing has been done by the mobility of the spinous processes. 
Other instruments which may be used are the double chisel of Esquirol, 
the knife-shaped chisel of Brunetti, and the rhachiotome and hammer 
of Amussat, the latter being much preferred in France to Luer's rha- 
chiotome, which is not approved of. If the rhachiotome is used as the 
seventh cervical vertebra is approached, both from above and below, 
the incisions are made more and more towards the side, as the canal 
is wider here, owing to the increased size of the cord at this spot. 
After the canal has been opened in the dorsal region with the saw, 
a pair of bone-nippers is used to pry up the portions of vertebra thus 
loosened, and the dura is exposed (Figs. 146, 147). The sawing can 
then be continued in both directions until the entire canal is opened, 
except the atlas and axis, which had better be cut with bone-forceps 
(Fig. 148). In using either bone- forceps or pliers be very careful 
not to produce artefacts of the cord. The cord at the first dorsal 
vertebra is then tied with a string, so as to have the situation accu- 
rately determined, or the first dorsal nerve may be dissected out and 
left attached to the cord. 

The spinal cord covered with its membranes may now be studied 
in situ, after which the dura and the spinal nerves are divided belozv the 
cauda equina. The dura being elevated with the fingers or forceps and 
pushed to one or the other side, the spinal nerves are cut, with a long, 
thin, narrow-pointed, sharp knife, close to their points of entrance into 
the intervertebral foramina. (Fig. 149.) The dura at the foramen 
magnum can best be severed from the bony margin above after the 
brain has been removed. The cord may be taken away with the brain 
attached if so desired. The spinal ganglia may be extracted with the 
nerves and cord by cutting away the articular processes and gently 
pulli lg the cord, by the dura, to the opposite side and severing the 
nerve as far in the foramen as possible. 



244 



POST-MORTEM EXAMINATIONS 



By making a median incision in the dura mater the cord is exposed, 
and can, of course, be removed. This procedure, however, is more 
liable to cause injury to the cord than the method given above. 

After freeing all points of attachment the cord must be very gently 
transferred to the table or tray for further examination. Study the 
dura for (i) thickness, (2) color, (3) blood, the cerebrospinal fluid 
for (1) pus, (2) blood, and the pia for (1) expansion, (2) thick- 
ness, (3) contained blood, and (4) color. Gentle palpation may 
reveal areas of softening or sclerosis. The further manipulation of the 
part will depend upon the extent of the examination required. If the 
cord is to be preserved for future study, the dura is opened in the 
median line throughout its entire extent, the blade being inserted at 
the lower end, and transverse incisions about one inch apart down to the 
pia are made in the cord. It may be hardened at the same time and in 
the same jar as the brain by curling it around that organ; but it is 
better to suspend it by the dura, with a small weight attached, in a long 
jar, or it may be kept in such a jar lying upon its side. In summer 
the jar should be placed in the refrigerator. 

If the examination is to be completed immediately, the cord is laid 
out on the table, with its anterior surface resting preferably on a towel 
or piece of cheese-cloth, and the dura opened throughout its entire 
length as already directed. Note is made of the conditions observed. 
Much valuable information can be obtained by the macroscopic exami- 
nation, especially if a hand-glass be used and diagrams made at the 
time. Then, with a sharp, thin knife, which should be moistened with 
water after several incisions, transverse sections about an inch apart are 
made through the cord and membranes; the under surface of the 
dura, however, is left uncut, in order that the cord may be replaced 
in its entirety. A careful operator may hang the cord over the index- 
finger of the left hand, keeping it in place with the thumb, and make 
the incisions there, the dura being sufficient to protect the finger. A 
microtome knife is admirably adapted for making the incisions. Areas 
of softening should not be incised, because of the inevitable disturbance 
thus produced in the relations of component parts. Froriep's incision 
of the spinal cord, one long longitudinal incision throughout the entire 
extent of the cord, is severely criticised by Virchow. 

Where the avoidance of disfigurement above the parts covered by 
clothing is a matter of great importance, sufficient room for opening 
the cervical canal can be obtained by making a crescentic incision from 



THE SPINAL CANAL AND CORD 



245 



the centre of one shoulder to the other, with the concavity towards the 
head, and dissecting up the skin. (Fig. 143, CD.) 

Sometimes it is advantageous to open the canal by removing the 
vertebral bodies through the long anterior incision with the body rest- 
ing on its back. Brunetti's chisels were devised for this purpose. 
After removal of the thoracic and abdominal viscera, the pointed guard 
is inserted in the vertebral canal, and the instrument, held parallel with 
the long axis of the spinal column, is driven forward with a mallet, 
thus severing the pedicles and removing the bodies or anterior wall. 
By this method the spinal ganglia are said to be rendered more easily 
accessible. The remaining steps are about the same as those described 
for the posterior incision. 



CHAPTER XV 

DISEASES OF THE BRAIN AND SPINAL CORD 

Abscess of the Brain. — There is a circumscribed collection of 
pus in or upon the brain substance, with or without a pyogenic mem- 
brane, (a) Micro-organisms, — e.g., Staphylococcus pyogenes, Strep- 
tococcus, the diplococci of pneumonia, gonorrhoea, and cerebrospinal 
fever, Bacillus coll communis, the bacillus of typhoid, influenza, etc. 

(b) Traumatism, (c) Extension of disease from the middle ear or 
mastoid cells and cranial bones, (d) Septic emboli from distant foci, 
— e.g., abscess of the liver, ulcerative endocarditis, putrid bronchitis, 
localized bone-disease, etc. (e) Actinomycosis and other mycotic 
germs (rare). Classification. — (a) Primary (rare) or secondary 
(common), (b) Single (from extension) or multiple (metastatic). 

(c) Large (size of a walnut or an orange) or minute (then usually 
multiple). Seats. — (a) Cerebrum, usually in the temporo-sphenoidal 
lobe (most common), (b) Cerebellum, especially in middle-ear dis- 
ease, (i) Acute abscesses, usually about blood-vessels; are minute, 
with no definite wall; contain pus mixed with reddish debris and 
softened brain matter. (2) Chronic abscesses may be superficial or 
deep; have a pyogenic membrane, which develops in from three to 
five weeks; pus has a greenish tint, an acid reaction, and may have 
a peculiar odor depending on micro-organisms. It may undergo fatty 
degeneration, but cystic formation is doubtful. 

Acromegaly. — A chronic disease of nervous origin, occurring 
most frequently in adults, and characterized by an overgrowth of the 
bones, especially those of the face and extremities, by malnutrition, 
and by impairment of the senses. Morbid changes are always found in 
the pituitary body (hypertrophy, colloid degeneration, tumors, etc.) 
and usually in the thyroid and thymus glands. There are marked 
hypertrophy of the bones of the face (especially the maxillae) and 
osteophytic growths on the bones of the hands and feet, with exag- 
geration of the normal ridges and tubercles. The thorax is enlarged 
and kyphosis may be present. The sternum is thickened, lengthened, 
and widened, as are also the ribs and clavicles. There may be hyper- 
trophy of the pharynx and larynx, leading to marked dyspnoea. In 
246 



DISEASES OF THE BRAIN AND CORD 247 

one of my cases there was found after death a sarcoma of the pituitary 
body; in another, all of the glands of the body appeared to be hyper- 
trophied. I have removed post mortem the pituitary body through 
the orbit. Under acromegaly may also be classed osteitis deformans, 
an affection which causes softening and distortion of the long bones 
of the body ; hypertrophic pulmonary osteo-arthropathy, where 
there is antecedent lung disease and the bones of the skull are not 
involved, and leontiasis ossea, an overgrowth of the bones of the 
cranium. In micromegaly the condition is the reverse of that found 
in acromegaly. 

An.emia Cerebri. — A condition in which the brain is temporarily 
or permanently deprived of part of its blood-supply. Due to: (a) 
Mechanical obstruction to the circulation, — e.g., valvular heart-lesions, 
thrombosis, embolism, or ligation of a vessel. (b) Hemorrhage. 
Classification. — (a) General or local, (b) Acute, subacute, or chronic. 
(c) Partial or complete. The membranes are pale: small arteries over 
the gyri are empty, though large veins are full. The brain substance is 
anaemic, the surface moist, few puncta vasculosa are seen, and the cere- 
brospinal fluid is increased. 

Aneurism of Cerebral Arteries. — Classification. — (a) Single 
or multiple, (b) Large or minute. Seats. — (a) Most frequent in 
branches of the middle cerebral artery, especially those of anterior 
perforated spaces. (&) May be cortical. The aneurisms are usually 
very small, varying in size from that of a pea to a cherry-stone (sel- 
dom larger), multiple, and may resemble bunches of grapes. If 
hemorrhage occurs in basal aneurisms, the internal capsule and basal 
ganglia are injured, the lesion usually being extensive. On the cortex 
the result of hemorrhage is much less grave. 

Apoplexia Neonatorum. — A form of hemorrhage of the brain 
occurring in the new-born, usually the result of traumatism. (a) 
Accidents during labor, from forceps, etc. (b) Congenital defects 
in blood-vessels, brain, or skull, (c) May result from prolonged and 
severe normal labor. Seats. — (a) Meninges (piarachnoid) most fre- 
quently, often bilateral, and usually at the base. ( h) May be between 
dura mater and skull; is accompanied by cephalaematoma. (c) May 
occupy the ventricles, (rf) May occur in brain substance aboul basal 
ganglia, (a) Sometimes found in parietal region and Sylvian fissure. 
I 1 1 Generally the hemorrhage is meningeal primarily, producing 
brain-lesions secondarily, such as atrophy and softening, by pressure. 



2 4 8 



POST MOR ri'M KXAMINATIONS 



(2) Cortical hemorrhage is represented by a clot, which may be 
encysted, softened, or organized, causing more or less injury to the 
brain. (3) When the hemorrhage is between dura and skull, fracture 
is said to be always present. 

Ataxia, Hereditary (Friedreich's). — A form of ataxic para- 
plegia occurring especially in young children, (a) The disease is 
sometimes hereditary, and it is not uncommon to have several mem- 
bers o\ the same family affected. (/;) More frequent in males than 
in females, (c) A specific lesion o\ the cord. (1) There is a gliosis 
of the posterior column of the spinal cord, clue to developmental errors 
(Osier). (2) Talipes equinus occurs in both feet. (3) Lateral curva- 
ture is common. 

Ataxia, Locomotor (Tabes Dorsalis). — A chronic disease of 
the nervous system, characterized by sclerosis of the cord and brain, 
and by incoordination, with motor, sensory, and trophic disturbances. 
(a) Male sex. (b) Adult life, (c) Syphilis, (d) Wet and cold. 
(c) Sexual excesses, etc. (1) Spinal Cord. — Externally the men- 
inges arc thickened and adherent. Posterior roots are atrophic and 
^\ a grayish tint. Internally sclerosis of the cord begins in the pos- 
terior-root zone, involving the outer layers of posterior columns in the 
lumbar region. The sclerosis gradually extends inward, involving 
successively the columns of Burdach and Goll; when the process 
reaches the upper dorsal region, it is confined to the column of Goll. 
The cord presents a flattened appearance posteriorly, the sides being 
somewhat contracted. The diseased areas are firm, grayish or grayish 
red in color, and the whole cord is often firmer in consistency. (2) 
Brain. — Changes of less consequence than in the cord may be sclerosis 
in restiform bodies, inferior peduncles of cerebellum, and certain 
cranial nerves, — the oculomotor, optic, and auditory. Atrophy of the 
optic nerve and hemiplegia may occur. Some recent writers con- 
sider paralytic dementia to be such a disease of the brain as locomotor 
ataxia is of the cord. (3) Peripheral nerves may show degeneration 
or even neuritis. (4) In later stages occur dermopathies and arthro- 
pathies, — e.g., perforating nicer of foot, herpes, etc., Charcot's joint, 
etc. There may be evidences of loss of control of sphincters. The 
essential lesion is a dystrophy attacking the peripheral sensory neuron. 
Erb 3 has found out ^\ a total of 1100 cases of tabes that there was 



1 Berliner klinische IVochenschrift, [904, vol. xli, nos. 1, 2, 3, and 4. 



DISEASES OF THE BRAIN AND CORD 



249 



an unmistakable history of syphilis or chancre in 89.45 per cent., syphi- 
litic antecedents were probable in all but 2.8 per cent., and even hero 
syphilis is suspected by Erb. In 96 cases of tabes Lesser x found an 
aneurism in 18. and speaks of these processes as the quartan mani- 
festations of syphilis. 

Caisson Disease. — A peculiar nervous affection, the result of a 
sudden reduction of atmospheric pressure. Occurs in bridge-builders, 
divers, etc., who. after working for hours under a pressure of two or 
three atmospheres, have suddenly returned to air of normal density. 
In fatal cases there is a marked destruction of nerve tissue in the pos- 
terior columns and the posterior portions of the lateral columns, 
forming fatty detritus and compound granular cells. Free gas bub- 
bles of nitrogen are said to exist in the circulatory system of those 
affected. 

Chorea. Acute. — (a) Female sex. (b) Early life (before the 
fifteenth year), (c) Heredity, (d) Bad hygiene, (e) Fright. (/) 
Bad habits. Xo constant lesions are found. Vascular changes, usually 
of a congestive type, such as hyaline degeneration, leucocytic infiltra- 
tion, minute hemorrhages, and thrombosis of small arteries, have been 
described. Possibly due to a specific organism. 

Congenital Anomalies. — Cranioschisis, rhachioschisis, hydro- 
meningocele. encephalocele, myelomeningocele, hypoplasia of different 
parts, as of the cerebellum, micrencephaly, hydrocephalus, internal and 
external porencephaly, idiocy, cretinism, micromyelia, total absence of 
parts, and anomalies of distribution. 

Cretinism. — A low form of idiocy, either congenital or acquired 
during the early years of life, and associated with anatomic changes 
in the thyroid gland, as absence, hypoplasia, atrophy, or goiter. It is 
endemic in certain localities, notably Switzerland, where goiter is 
prevalent. Heredity bears a causative relation. The condition usually 
appears at birth. The child is stunted and dwarfish in appearance. 
The trunk is large in proportion to the development of the head, hands, 
and feet. The head is flat, the face broad and expressionless, the 1 
are dull and stupid, the nose is flat and depressed, the lips are thick, 
and the tongue is large and usually protrudes. The teeth are carious; 
the hair is thin, brittle, and harsh to the touch ; the skin about the hair 
is dry and scurfy. The abdomen is prominent; the legs are short and 

1 L. c, no. 4, p. 80. 



j- () POST-MORTEM EXAMINATIONS 

thick, the hands and feet undeveloped. The skin is yellow, leathery, 
and rough to the touch. 

Delirium, Acute. — The post-mortem findings are usually nega- 
tive. There may be great venous engorgement of the meninges, and 
the cortex and blood-vessels may show exudation and leucocytic infil- 
tration into the lymph-spaces and sheaths. Careful examination of 
the lungs and ileum should be made in fatal cases. 

Encephalitis, Acute. — Due to: (a) Acute infectious disease. 
(b) Traumatism, (c) Intoxications. The minutest foci of inflam- 
mation are not recognizable by the unaided eye; later stages have a 
pinkish appearance or are represented by clusters of small dark-red 
hemorrhagic foci. When suppuration follows, these areas take the 
form of yellowish-white patches whose tissue soon liquefies and 
becomes purulent. 

Erythromelalgia. — In this condition there is arteriosclerotic 
thickening of the blood-vessels with diminution of their lumen (oblit- 
erative arteritis) and some involvement of the peripheral nerves. 

H^ematomyelia. — Hemorrhage into the cord, (a) Traumatism. 
(b) Exposure, (c) Convulsions, (d) Tumor, (e) Syringomyelia. 
(f) Myelitis, (g) Male sex. (h) Middle life. The cord is usually 
enlarged, occasionally lacerated. The blood is generally confined to 
the gray matter, but may escape beneath the membranes. 

Hemiplegia in Children. — Causes: (a) First or second year. 
(b) Traumatism. (c) Embolism or thrombosis, (d) Congenital 
defect. Classification. — (a) Embolism, thrombosis, or hemorrhage. 
(b) Atrophy and sclerosis, (c) Porencephalon. (i) The results of 
embolism, thrombosis, or hemorrhage depend on the extent and 
rapidity of the formation and on location. When the process is an 
acute one and extensive, it is either immediately fatal or leads to more 
or less extensive destruction of the brain substance; there is a ten- 
dency to softening or suppurative change. (2) Atrophy and sclerosis 
may involve a group of convolutions, an entire lobe, or even a whole 
hemisphere. The affected gyri are firm, hard, and atrophied, con- 
trasting sharply with the normal tissue. They may be uniform in 
appearance or there may be nodular projections. In porencephalon 
there is loss of substance, with the formation of cavities or cysts at 
the surface of the brain. 

Hemorrhage, Cerebral. — The most common cause (sixty per 
cent.) is rupture of the lenticulostriate artery. Classification. — (a) 



DISEASES OF THE BRAIN AND CORD 25 1 

Basilar, (b) Cortical. In basilar hemorrhage section of the brain 
substance frequently shows miliary aneurisms, which are seen as small 
dark bodies along the course of the blood-vessels penetrating the ante- 
rior perforated spaces. Aneurism of a branch of the circle of Willis 
may be found. Endarteritis and periarteritis are found in the cerebral 
vessels. At the seat of a recent hemorrhage the brain has a dark-red. 
softened appearance, the tissue being reduced to a coagulated or pulp}" 
mass of detritus. When the hemorrhage has been extensive, the 
remainder of the brain is anaemic. The gyri are more or less flattened, 
from extravasated blood, and the sulci are indistinct. Hemorrhages 
are most common near the corpus striatum towards the outer section of 
the lenticular nucleus. They may be small and limited to the lenticular 
body and internal capsule or may break into the lateral ventricle. Ven- 
tricular hemorrhage is rare. It is usually bilateral. Meningeal hemor- 
rhage is usually caused by fracture of the skull or rupture of a blood- 
vessel. The hemorrhage may be small or large. It may be above or 
below the dura or between the pia and the arachnoid. The hemorrhage 
may be primary into the fourth ventricle. 

Hemorrhage ixto the Spinal Membranes. — Extrameningeal 
hemorrhage may be extensive, without compression of the cord. Rup- 
ture of an aneurism into the spinal canal may produce profuse and 
rapidly fatal loss of blood. There may be little demonstrable morbid 
change. Intrameningeal hemorrhage usually occurs in scattered areas 
as the result of acute infectious fevers. More extensive hemorrhages 
result from epilepsy, tetanus, and strychnine poisoning. Occasionally 
hemorrhage into the spinal meninges may ascend to the brain. 

Hyperemia. Cerebral. — This may be: (a) Active, (b) Passive. 
The cerebrum is congested, the blood-vessels are somewhat dis- 
tended, and petechial hemorrhages are numerous. On section the 
gray substance contrasts very markedly with the white; the former 

' a brick-dust color; the latter shows many punctate hemorrhages. 
_ In passive congestion the veins of the cortex are distended; the 
matter lias a deeper color and its vessels are full. The gray mat- 
ter shows distention of the smaller veins, which on section allow their 
contents to exude as drops of blood of various sizes. Excessive 
passive hypenemia may result in cerebral oedema. 

Leptomeningitis, Acute Cerebrospinal. — Acute inflammation 
of the pia and arachnoid of the brain and spinal cord. Causes: (a) 
Acute infectious fevers, (b) Injury or disease of the base of 1 he skull. 



jz,2 POST-MORTEM EXAMINATIONS 

(c) Extension of disease from nose, ear, or Eustachian tube, (d) 
Pyaemia. The organisms most commonly found are the meningo- 
coccus, the pneumococcus, the tubercle bacillus, and the cocci of in- 
flammation; more rarely, the bacilli of influenza and of typhoid, the 
colon bacillus, and the gonococcus. Classification. — (a) Simple or 
traumatic, (b) Purulent, (c) Tuberculous, (i) In simple or puru- 
lent meningitis the membranes are thickened, the blood-vessels dilated, 
and there is more or less exudation, which may be serous, serofibrin- 
ous, or purulent. The exudation may be so extensive as to cover up 
the convolutions. The inflammatory process is most marked in the 
basilar portions. It may be unilateral or bilateral. In the former the 
condition is due to extension from neighboring parts. (2) The 
tuberculous form of the disease is ususally cortical as well as basilar. It 
begins as a miliary tuberculosis, and in the early stages exudate is not 
extensive. The ventricles also may be involved and present consider- 
able distention and softening; they seldom suffer in other forms of 
the disease. 

Meningitis, Acute Cerebrospinal. — An acute infectious dis- 
ease, especially of early life, characterized by inflammation of the 
membranes of the brain, with an exudation of fibrinopurulent material, 
chiefly towards the base, and due to the Diplococcus intracellular is. 
( 1 ) Membranes of the Brain. — In acute fatal cases there is intense 
injection of the pia and arachnoid, with a little exudate. In more 
chronic cases there is a formation of fibrin or of pus, or of both; 
this is most marked at the base of the brain. The meninges are much 
thickened and opaque. The larger blood-vessels are overfilled and 
many of the smaller ones are obliterated. Sometimes the entire cortex 
is covered with a thick purulent exudate, and there may be much 
lymph along the larger fissures and in the sulci. In acute cases the 
ventricles are dilated, the ependymae are inflamed, and the cavity may 
contain pure pus. (2) Cranial Nerves. — The nerves usually involved 
are the second, fifth, seventh, and eighth. They are often embedded 
in the exudate. Micro-organisms may be found in the fibrin. (3) 
Brain Substance. — This is softer than normal, has a pinkish color, 
with foci of hemorrhage and of brain softening. (4) Lungs. — Pneu- 
monia and pleurisy may occur. The lungs are often congested, with 
evidences of bronchitis. (5) Abdominal Organs. — The liver is rarely 
altered. Acute nephritis is sometimes present, and the intestines may 
show swelling of the follicles. (6) Skin. — There may be rose-colored, 



DISEASES OF THE BRAIN AND CORD 



25c 



hyperaemic spots, resembling the typhoid rash, urticaria or pemphigus, 
and in rare instances gangrene. (7) Eye. — Neuritis is common, and 
there may be acute papillitis. Purulent chorioido-iritis or even kera- 
titis sometimes occurs. (8) Ear. — Otitis media develops from direct 
extension, and frequently leads to abscesses. In one of my cases 
the bacillus of tuberculosis was found associated with the meningo- 
coccus. In two fatal cases examined by me there was a history of 
traumatism, though no sign of this was found at the postmortem. 
During an epidemic domestic animals, as the goat, should be watched 
for signs of disease. 

Mexigo-excephalitis; Chroxic Diffuse or Deep Chronic 
Leptomexixgitis. — (a) Male sex. (b) Early adult or middle life. 
(c) Syphilis, (d) Alcoholism, (e) Certain occupations, as those of 
artists, navy and army officers, etc. The membranes of the brain are 
thickened and opaque and more or less extensively adherent to the 
cortex, which is torn on attempting to remove them. The convolu- 
tions of the brain are atrophied, especially in the frontal and parietal 
regions. The gray matter may be obscurely outlined. The white 
matter is firm in consistency. The ventricles are dilated and the 
ependymse granular; frequently there are areas of hemorrhage or 
softening associated with chronic arteriosclerosis. There is an increase 
in the cerebrospinal fluid. Usually sclerosis of the posterior columns, 
with involvement of the lateral, is found. There may be an extraor- 
dinary development in the lymph connective system of the brain, 
with a parallel degeneration and disappearance of the nerve-elements 
and the axis-cylinders, and finally shrinking and extreme atrophy of 
the parts involved. 

Muscular Atrophy, Progressive (Spinal). — (a) Male sex. 
(b) After the thirtieth year. (1) Macroscopically there is great mus- 
cular wasting, beginning usually in the thenar and hypothenar emi- 
nences and thence extending to the general muscular system. In 
marked cases the subject may be reduced " to skin and bone." De- 
formities and contractures result and lordosis is almost always present. 
pically the muscles undergo fatty and sclerotic change 
and the terminal ends of the motor nerves are degenerated. (3) 
Examination of the cord shows the anterior roots corresponding to 
the diseased muscles to be atrophied. Neurogliar tissues show marked 
increase, most conspicuous in the anterolateral tracts. The defenera- 
tion of the gray matter extends to the medulla. Large ganglion-cells 



2 e 4 POST-MORTEM EXAMINATIONS 

in the motor cortex may be wasted. In a case at Elwyn which I 
examined post mortem the diaphragm was easily seen through when 
held up to the light. 

Myelitis, Acute. — (a) Traumatism, (b) Exposure, (c) Cer- 
tain infections. (d) Disease of the spine, (e) Disease of the cord. 
( i ) The cord is swollen and soft and the pia injected. On incision a 
diffluent fluid may escape. The distinction between gray and white 
matter is often lost. Hemorrhages are frequent. (2) Histologically 
the nerve-fibres are swollen, the axis-cylinders beaded, myelin droplets 
abundant, and corpora amylacea may be seen. The ganglion-cells are 
swollen, irregular in outline, and exceedingly granular and vacuo- 
lated. In the removal of the cord in these cases great care must be 
taken not to produce artefacts. 

Myelitis from Compression. — (a) Caries of the spine, (b) 
New growths, (c) Aneurism, (d) Parasites, (e) Distention of 
central canal with inflammatory liquid or blood. Changes appear first 
in the white matter, the fibres of which may within six hours swell 
up and disintegrate. 

Poliomyelitis, Acute Anterior. — (a) Early life, (b) Boys 
more susceptible than girls, (c) Acute infectious fevers, (d) Proba- 
bly a specific micro-organism. (1) The seat of the lesion is in the 
part supplied by the anterior median branch of the anterior spinal 
artery. Cervical or lumbar portions of the cord are most often 
affected. (2) In the early stages the lesion is an acute hemorrhagic 
myelitis, with rapid destruction of the large ganglion-cells. (3) 
The nerve-fibres of the anterior roots corresponding to the ganglion- 
cells destroyed break down and disappear. (4) Certain anterior 
nerve-roots are atrophied, and the muscles innervated by them waste 
and become fatty and sclerotic. 

Raynaud's Disease. — A form of vasomotor neurosis causing local 
syncope, cyanosis, and symmetrical gangrene, affecting especially the 
fingers and toes, caused by spasm and constriction of the small blood- 
vessels. 

von Recklinghausen's Disease. — This is a general fibrosis of 
the peripheral nervous system. Nuthall and Billington * report the 
necropsy of a case. 

Sclerosis, Insular (Disseminated Sclerosis). — Its cause is 



1 Lancet, December 27, 1902, p. 1751. 



DISEASES OF THE BRAIX AND CORD 



255 



not definitely known. Is more common in the young than in the old. 
Sclerotic areas are usually small, of a grayish or whitish color, widely 
distributed in the brain and cord and in the gray and white matter. 
They are more abundant about the ventricles, the central canal, the 
pons, the cerebellum, and the basal ganglia. The patches are firm, 
dry, and sharply defined from the surrounding tissue; in some cases 
they may be less firm and not so well defined. Microscopically there 
is a marked increase of neuroglia, the medulla of the nerves is de- 
stroyed, and the axis-cylinders persist. 

Spina Bifida. — There is a congenital defect in the union of the 
laminae of one or more vertebrae, associated with malformation of 
the spinal cord or its membranes. It occurs most frequently in the 
lumbar regions, and persons may live to a good old age thus affected. 

Syringomyelia. — Syringomyelia is a chronic affection of the 
spinal cord characterized anatomically by the pathologic formation of 
cavities in its gray matter, and clinically by peculiar disturbances of 
sensibility associated with trophic disorders. Causes : (a) Embryologic 
malformations, (b) A gliosis, (c) Traumatism, (d) Development 
of embryonal neurogliar tissue in which hemorrhage or degeneration 
takes place with the formation of cavities. (1) The characteristic 
lesion is a cavity which forms in the cord in or near the central canal 
and extends into the gray matter of the anterior, or more frequently 
the posterior horns. It is most often situated in the cervical and tho- 
racic portions of the cord. (2) On transverse section the cavity may 
be oval, circular, or narrow and fissure-like, or it may present the 
appearance of two or more cavities independent of each other or inter- 
communicating. (3) The contents of the cavity are usually a colorless 
liquid. Occasionally it may be a yellow or brown gelatinous substance, 
or it may consist of blood and the products of its degeneration. The 
white matter of the cord in moderate cases is unaffected, but where the 
cavity is large and pressure from the sclerotic tissue has become great, 
the white matter is in its turn involved, being crowded to the periphery 
and more or less unable to carry on its functions. 

Tumors. — Tumors and cysts of the brain are of common occur- 
rence and of the greatest variety, such as fibro-endothelioma, sarcoma, 
psammosarcoma, fibroma, osteophytes, perithelioma, lipoma, myxoma, 
glioma, gliosarcoma, angioma, neurofibroma, and neuroma. Of the 
granulomata, syphilis, tuberculosis, and actinomycosis are the most 
common, and of the parasites the cysticercus and echinococcus. 



CHAPTER XVI 

EXAMINATION OF THE NASOPHARYNX,, EYES, AND EARS 

EXAMINATION OF THE NASOPHARYNX. 

In order to expose to view the upper air-passages, nasal, pharyn- 
geal, laryngeal, and accessory cavities, epiglottis, etc., Harke's 1 method 
has come into general use. If the procedure is properly carried out, 
the parts when returned to their normal position present no noticeable 
deformity, though during the examination such a result seemed almost 
impossible. 

Harke's Method. — The brain having been removed and the ex- 
amination of the skull completed, the anterior skin flap is dissected away 
from the frontal bone down to the root of the nose, while the posterior 
flap is dissected away some distance below the foramen magnum. It is 
not necessary that the primary incision of the scalp behind the ears be 
made lower than the mastoid process on each side. Next, directly in the 
median line, the skull is cleft with a small saw into two lateral portions. 
For the sake of convenience the saw markings may be divided into two 
sets (Fig. 150), the first starting from the front in the frontal bone, ex- 
tending down to the nasal bone, and continuing to the foramen magnum 
(A B), and the other starting at the occipital bone and extending to 
the foramen magnum (CD). The atlas and axis are sawed through 
if much room be desired. The sawed portions are now separated by 
means of a chisel and hammer, any portions of mucous membrane that 
may appear being severed with a knife or scissors. By means of strong 
lnteral traction the two segments may be pulled apart, and the entire 
region down to the vocal cords will thus be exposed. Usually the in- 
cision passes to one or the other side of the nasal septum. The walls 
of the accessory cavities are readily cut away with strong scissors, and 
a plain view is obtained of the maxillary sinuses as well as the frontal, 
sphenoid, and ethmoid. Even the epiglottis and vocal cords can be 
examined by this method (Fig. 151). In order to view the parts 
better, light may be thrown in by means of a mirror. 

Another method is to drill holes just in front of the sphenoid and a 
little behind and to the right and left of the crista galli, and then with a 

1 Berliner klin. Wochenschrift, 1892, no. 30, p. 742; Virchow's Archiv, 1891, vol. 
exxv, p. 410. Beit rage zur Patlwlogie und Therapie der oberen Athmungswege, 
Wiesbaden, 1895. 
256 




Fig. 150 —Method of examining nasopharynx, eyes, and ears. The sawing for opening the naso- 
pharynx is done in the median line from the frontal bone, A, to the anterior portion of the foramen mag- 
num, /?, and from the occipital bone, D,to the posterior portion of the foramen magnum, C. The sawing 
can best be accomplished by standing on the table directly over the head, the finger-saw being especially 
useful at the beginning and the end of the operation, /i and F, lines of incisions for the removal of the 
eyes ; G, situation of the ear-ossicles ; Ay /and L Af.YO, lines for removal of the ear-ossicles ; P and Q, 
drill-holes for saw-markin?s in the oval method of examining the nasopharynx. 



EXAMINATION OF THE EYES 257 

saw or a chisel make an ovoid incision extending almost to the foramen 
magnum, and remove the portion of bone which hides the nasopharyn- 
geal cavities. (Fig. 150, P. Q.) The two lateral halves are then 
brought together and wired as in Fig. 152. Nasal obstruction may 
cause deformities of the upper jaw, teeth, and palate. 1 

EXAMINATION OF THE EYES. 

For this purpose a triangular piece of the orbital plate of the frontal 
bone is broken through with a hammer or chisel, care being taken not to 
injure the optic nerve in the optic foramen, the remaining portion of the 
eye and the nerve being well protected. (Fig. 150, E and F.) The 
direction of the nerve can be determined by observing the situation of 
its exposed portion, and the chiselling done a small distance on either 
side of its normal position. The pieces of bone are removed with the 
nippers and the optic nerve is carefully dissected out, its cut end being 
held with the fingers or forceps. The capsule of Tenon and the fat are 
removed, and the entire eye is excised or, if this is not permitted, an 
incision is made in the sclerotica posterior to the conjunctival attach- 
ment. This requires a very sharp knife, as the tissue is extremely 
tough. A circular incision is made around the entire eye, and the 
fundus is exposed. A piece of dark cloth or cotton dipped in ink is 
placed in the remaining portion of the eye in order to hide any dis- 
figuration, and the cavity is packed with cotton. 

If only a macroscopic examination of the retina and other structures 
is desired, the retina may be floated out in normal salt solution and then 
separated from the choroid. If the retina is to be fixed for microscopic 
examination, the incision should be as nearly equatorial as possible and 
the fundus placed immediately in Orth's or Miiller's fluid or ten per 
cent, formalin, or fixed by exposing for three minutes to the fumes 
from a one per cent, osmic acid solution heated just to the boiling point. 
The eye is then put for twelve hours into Lindsay Johnson's mixture: 

Potassium bichromate, two and one-half per cent 70 parts. 

Osmic acid, two per cent 10 parts. 

Platinic chlorid, one per cent 15 parts. 

Acetic or formic acid (to be added just before using) .... 5 parts. 

The gloss of the cornea disappears as soon as death comes on. 
After twenty-four or thirty hours, and often earlier, the bulbus softens 

'Collier. Lancet, Oct 02, p. 1038. 

'7 



jho POST-MORTEM EXAMINATIONS 

making a second incision at right angles to the one across the vertex 
of the skull, thus passing through the occipital protuberance. Or, it 
may be considered as a continuation of the median incision of the 
hack in the removal of the spinal cord to the incision going across the 
skull. The ilaps thus produced are then dissected away from the 
underlying part, and salivary glands, exocranial sinus, mastoid process, 
articulation of the jaw, intercarotid bodies, etc., examined with ease. 
A study of fifty-four mixed tumors of the salivary glands has recently 
been made by Wood. 1 The parotid gland may be the seat of primary 
tuberculosis. Salivary calculi are sometimes found. Robery, in a 
paper read in 1904 before the Chicago Medical Society, gives an excel- 
lent bibliography of this subject. 

1 Annals of Surgery, 1904, Jan., p. 57 and Feb., p. 207. 



CHAPTER XVII 

BONES AND JOINTS * 

A complete autopsy ends with a careful inspection of such por- 
tions of the osseous system as may need to be investigated and which 
have not come under observation in those parts of the body already 
studied. Unfortunately, a thorough examination of the bones and 
joints cannot always be attempted on account of the unavoidable dis- 
figurement it entails. However, by ingenuity in technic and skill in 
restoration of the body even the removal of large portions of the skele- 
ton may be successfully concealed. The X-rays have done much in 
recent years to facilitate the study of both normal and abnormal osseous 
structures, and may often be employed to great advantage at the post- 
mortem, as in showing the exact location of a bullet. The time 
required for exposing the photographic plate to the Rontgen rays seems 
to be longer than in the examination of the living subject. 

Arthritis. — Inflammation in a joint begins either in the synovial 
membrane or in the bone, and affects all the structures of the joint 
(panarthritis) and, often secondarily, surrounding parts (periar- 
thritis). It may arise from trauma, infection, as a sequel of pyaemia, 
erysipelas, gout, gonorrhoea, tuberculosis, syphilis, scarlatina, dysen- 
tery, typhoid fever, pneumonia, measles, or as secondary to bone dis- 
ease. It may be gouty, purulent, ulcerative, ankylosing, infective, 
syphilitic, tuberculous, etc. Lipomatous, fibrous, and cartilaginous 
growths may occur in a joint. Rice bodies probably arise from hyaline 
portions of the synovial membrane. 

Acute arthritis consists in inflammation of the synovial membranes 
and fringes, at times with hemorrhagic extravasations, and distention 
of the capsule by effusion, in which float flakes of fibrin. The soft 
parts around the joint are swollen. The serous and serofibrinous forms 
usually terminate in resolution, without marked changes. The fibrin- 
ous form frequently results in the formation of more or less extensive 
adhesions. Empyema of a joint, arthropyosis, being generally asso- 
ciated with osteomyelitis due to metastasis from other foci, occurs 
usually in the knee, involving later many other joints. The synovial 

1 Based on the text-books of Ziegler and Green. 

261 



262 POST-MORTEM EXAMINATIONS 

membrane and the articular ligaments become dark red in color, 
swollen and infiltrated, and covered with pus; later the cartilage and 
lastly the bone (molecular necrosis) are attacked, often causing dis- 
articulation of the ends of the bones. Perforation may be primary or 
secondary. A purulent effusion, remaining a long time without serious 
destruction, is called catarrhal synovitis. 

Chronic Inflammations. — Chronic articular dropsy (hydrarthrosis) 
is a serous or serofibrinous inflammation, usually seen in the knee, 
wrist, or elbow. The synovial membrane is thickened, indurated, and 
may have patches of fatty degeneration. In the knee the patella may 
be lifted and the bursse distended by a thick or thin or gelatinous secre- 
tion, and the synovial membrane may protrude through the fibrous 
bands of the capsule. The synovial tufts become large and projecting; 
the joint-cartilages degenerate and proliferate. Adhesions or destruc- 
tion of the joint may follow. 

Chronic purulent arthritis is usually associated with tuberculosis 
or is due to extension from adjoining parts. The capsular ligaments 
and synovial membranes are infiltrated and covered with fibropurulent 
deposits ; the cartilages are cloudy, fibrillated, or necrotic, the marrow 
suppurating, and the joint filled with pus or numerous abscesses form- 
ing around the joint. Ankylosis or dense fibrous adhesions are found 
in cured cases. 

Chronic, dry, ulcerative arthritis occurs in old age, accompanying 
neuropathic disorders, or as a sequel to rheumatism. It consists in a 
proliferation of the synovial membrane, forming fringes, and in scle- 
rotic thickening of capsule and ligaments. Fibrillation and cleavage 
of the cartilages, with patches of calcareous, amyloid, or fibroid degen- 
eration, may occur. The denuded bone of the articulating surfaces 
may ulcerate or become sclerotic and waste, the capsule becoming so 
large that dislocations may occur. In the senile form the hip is usually 
affected, but the shoulder, elbow, phalangeal joints, and the patella of 
the knee may be involved. In tabes dislocations are very common in 
knee, shoulder, and elbow. 

Arthritis deformans, chronic gout, or rheumatoid arthritis, is a 
chronic disease of the joints, characterized by degenerative changes in 
the cartilages and synovial membranes, by periarticular formation of 
bone, and great deformity (Osier). It is often associated with infec- 
tious diseases, as gonorrhoea, gout, and rheumatism. In all forms the 
articular surfaces are hyperplastic and softened. Later, absorption 



BOXES AND JOINTS 263 

takes place, the ends of the bones becoming eburnated and polished; 
the head of the femur has entirely disappeared; generally it becomes 
conical, flat, or broad. The bone marrow liquefies, forming cysts; 
subchondral cysts and deep-seated bone cavities occur. At the edges, 
where the friction is less, irregular nodules (osteophytes) develop and 
calcify. Capsules, synovial membranes, fringes, and ligaments thicken 
and become infiltrated with lime salts. There is always a complete 
absence of uric acid. Great deformity, not infrequently ankylosis and 
dislocation, occurs. There is often marked atrophy of both bones and 
muscles. Arborescent lipomata are found. The smaller joints of the 
hands and feet are usually first affected, the fingers being deflected to 
the ulnar side. In severe cases all the joints may be more or less 
involved. In old people the disease is apt to attack the hip, knee, 
shoulder, or spine. Spondylitis deformans is due to the formation of 
osseous bridges between the vertebrae. Heberden's nodosities, a form 
of the disease, consist of small nodes or tubercles about the dorsum 
of the phalanges; this form very rarely affects large joints, as the knee. 

Gouty arthritis is the deposition of urates in the articular structures, 
usually in the metatarsophalangeal joint of the great toe (podagra) or 
a finger- joint (cheiragra). The periosteum, tendons, ligaments, and 
skin are more or less inflamed. The joint contains a clear fluid, with 
crystals of sodium urate, sodium chlorid, calcium carbonate, and cal- 
cium phosphate, hippuric acid, and other uric-acid compounds. Chalky, 
mortar-like, nodular masses, tophi, are found in the matrix of cartilage 
and ligaments. In old cases these are also found in the bone, peri- 
osteum, tendons, and bursse. Fibrillation and erosion of the cartilages 
cause abscess-like cavities, which may open externally. 

Gonorrhoea! arthritis occurs in one knee-joint, between the third 
and the sixth week of the disease. It has also been seen in an ankle 
and hip. There is a fibrous metaplasia, also a fibrous or osseous 
ankylosis. Ulceration of the cartilage, bone, and capsular tissue may 
occur, as a rule, with a purulent effusion. 

Rheumatic arthritis occurs in several joints at one time, generally 
in the hip, shoulder, and jaw. It begins as a hyperaemia of the synovial 
membranes, with an increase of fluid, followed by thickening and 
elongation of the ligaments and later by absorption or ossification of 
the interarticular cartilages, which become rough, fibrillated, and often 
converted into a tough, felted mass. Finally, there are induration and 
eburnation of the bony extremities. It may involve joints in succes- 



264 POST MORTEM EXAMINATIONS 

sion, and, in rare cases, all the joints. It always causes ankylosis, by 
fibrous adhesions of the ligaments and bony deposits in and around 
the joint. 

Chronic ankylosing arthritis is the most common anatomic feature 
of chronic rheumatism, and is due to a vascularization and fibrous 
metamorphosis of the articular cartilages, with coherence of the opposed 
cartilages. 

Spinal or neurogeneous arthritis, usually associated with tabes dor- 
salis, syringomyelia, degeneration of the anterior horns of the gray 
matter, arising from section of spinal nerves, consists in a rapid 
destruction of the articular ends of bones, thickening and ulcerative 
destruction of synovial membranes and ligaments, and a serous effusion 
into the joint, with swelling of the surrounding tissue and spontaneous 
dislocation. 

Syphilitic and tuberculous arthritis are described elsewhere. I have 
had one case of pneumococcal arthritis of the knee, with streaky hyper- 
emia of the skin, boggy swelling, purulent infiltration, and hemor- 
rhagic effusion. Toxic arthritis, due to alcohol, occurs, usually in 
small joints, and always associated with enlarged liver, spleen, and 
lymphatic glands. 

Degenerations generally occur in the cartilage of a joint. After 
hemorrhage into a joint, haematoidin is often found as crystalline and 
amorphous masses in the superficial cells. Ochronosis produces diffuse 
brown patches in cartilages, due to saturation of the matrix with some 
unknown coloring matter. Mucoid degeneration of the matrix pro- 
duces a turbid fibrillar appearance, which may go on to complete dis- 
integration, and is often associated with fatty change in the cells. 
Fatty degeneration, a translucent gray material, appears, in senile 
softening, associated with calcification; and in chronic inflammatory 
disease. It attacks mainly the costal cartilages, but may occur in 
margins of the articular cartilages, and in places where the matrix is 
already in a process of fibrillation and degeneration. Hyaline and 
amyloid degenerations occur in the capsules and cartilage-cells. Amy- 
loid degeneration may also affect the matrix. 

Atrophy. — Acquired or true atrophy is : ( 1 ) eccentric, the bone 
being normal in size, but on section showing great increase in the 
cavities and in the amount of the cancellous tissue, and decrease in the 
compact tissue; (2) concentric, the bone being slender and the external 
compact tissue showing local defects (osteoporosis), or being exces- 



BOXES AND JOINTS 265 

sively thin and brittle (osteopsathyrosis, fragilitas ossium). The me- 
dullary canal is always contracted. 

Atrophy may follow trauma, such as fracture, luxation, or epi- 
physeal injury, and disuse, as seen in old stumps and unset fractures. 
Pressure often thins the bones markedly. In hydrocephalus the inter- 
nal surface of the skull may be rough, or the inner table may be entirely 
absorbed. The Pacchionian bodies often make deep pits in the tem- 
poral bones. The vertebra, sternum, and other bones may be found 
deeply eroded and perforated by aneurisms and tumors; even scars 
may cause atrophy of the bone upon which the}- make pressure. 
Tumors of the marrow, periostitis, and osteomyelitis also cause atrophy 
of the bone by their pressure. A peculiar type of atrophy is seen in 
the aged, affecting those bones with only a slight muscular covering, 
as parietal, maxillary, and pelvic bones. The external table of the 
skull ma}- be entirely resorbed. Perforation of the entire thickness 
has occurred, bony deposits being often found at the same time on 
the inner table. The bone is rough, dull, and lustreless, with shallow 
erosions, not uniform in shape or position. Nervous diseases (neuro- 
pathic and neuroparalytic), infantile paralysis, inflammation, rickets, 
and many other pathologic conditions are often associated with osseous 
atrophy. 

Chondritis. — This affection is often a sequela of severe arthritis; 
it usually occurs in articular cartilages, which become turbid and dis- 
integrate. Erosions, caries, and more or less extensive necrosis are not 
uncommon. Hypertrophic proliferation, general or local, may occur 
with any productive inflammation of the cartilage or fibrous tissue of a 
joint. It is common in arthritis deformans and tuberculous arthritis. 
In cartilage it is nodose or tuberculous, while in the capsule or synovial 
membrane it appears as a diffuse thickening or as a papillary ex- 
crescence. Loose bodies, usually found in the knee, elbow, and wrist, 
rarely in the hip, shoulder, elbow 7 , or ankle, may be single or numerous, 
a knee with 1047 °*~ these bodies having been reported. These may be 
entirely free or attached by a slender stalk. They may be composed 
of fibrin, the remains of hemorrhage into the joint, or may be a pro- 
liferation of the synovial or fatty tufts, pieces of bone or cartilage 
detached by violence, foreign bodies which have penetrated the bone, 
loosened nodular masses, cartilaginous, osteomatous, fibrous, lipoma- 
tous, or lipoma-arborescent, or displaced semilunar cartilages. These 
bodies are usually oval, lenticular, or devious in outline, often faceted. 



2 66 POST-MORTEM EXAMINATIONS 

They are associated with arthritis deformans and rheumatoid arthritis, 
and in many cases appear without signs of previous inflammation. 

Dislocations of the semilunar cartilages are due generally to sepa- 
ration i)\ the anterior attachment of the cartilage from the tibia, which 
may be torn transversely through the edge of the meniscus or split 
longitudinally. A central tear has also been described. Cartilages, 
infrapatellar pad, and ligamentum alare are usually thickened. The 
displacement is inward, towards the centre of the joint, so that the 
leg cannot be extended. 

Fractures and Dislocations. — Fractures, the most common 
injuries to bones, are either complete or incomplete. A certain amount 
of repair callus will be found in all cases. Contiguous bones, as tibia 
and fibula, may coalesce during repair and lead to a synostosis. In 
cases with great displacement, with soft parts between the fragments, 
with existing debility or other unfavorable conditions, there may be no 
union, or simply a firm, fibrous adhesion (syndesmosis), or a false 
joint (pseudoarthrosis). Compound fractures, affording a favorable 
opportunity for the introduction of pyogenic organisms, are often 
associated with caries, necrosis, or osteomyelitis. 

Diastasis, a pathologic separation of the epiphysis from the di- 
aphysis, occurs usually as a sequela of accident or ulceration, the 
epiphysis being pushed off by the resulting granulations. It is most 
common in the upper part of the femur, in the lower portion of the 
humerus, and in the tibia. In rare cases the dislocation may take place 
between the manubrium and the gladiolus, or the head of the femur 
may be found loose in the acetabulum. 

Congenital dislocation of hip, single or double, is associated with 
softening of ligaments, effusion, fungous synovitis, hydrarthrosis, 
caries, arthritis, and arrest of development. The acetabulum is nar- 
rowed, elongated, less concave than normal, and occasionally filled with 
fat, connective tissue, or exostoses. The head of the femur is flattened, 
but larger than the acetabulum; it lies on the dorsum of the ilium or 
obturator foramen; the neck may be wanting; or it may be atrophied. 
If the patient has walked, there is usually a depression of the ilium 
and some lordosis. The gluteal muscles are contracted, the unused 
muscles atrophied, and the pelvis is contracted above and expanded 
below. Congenital luxation of the sternum has been reported. If 
acquired dislocations with rupture of the capsule, tendons, ligaments, 
muscles, and other structures around the joint be not reduced, the 



BONES AND JOINTS 267 

muscles and ligaments may atrophy, the synovial fluid be destroyed, 
and the bone be partially absorbed, or the bones may unite by firm, 
fibrous, cartilaginous, or bony adhesions (ankylosis). This may also 
follow non-use of a part, articular disease, trauma, phlegmonous ery- 
sipelas, burns, or as a sequela of tuberculous, gonorrhceal, gouty, rheu- 
matic, syphilitic, neurotic, or puerperal affections. A form of anky- 
losis of the spine is sometimes seen in typhoid fever. Congenital 
ankylosis of the entire skeleton has occurred. False ankylosis is due 
to bands of cicatricial tissue, adhesions of the ligaments and capsule, 
or organization of inflammatory deposits. 

Injuries. — Cuts, gunshot wounds, and stabs may result in acute 
inflammation, effusion of blood, empyema, ulceration of articular cap- 
sule, necrosis of cartilage and bone, or a more or less complete disor- 
ganization of the entire joint. Septicaemia and pyaemia may supervene. 
Crushing injuries to joints almost always end in abscess, usually asso- 
ciated with bony or cartilaginous fragments, which remain as foreign 
bodies in the joint. 

Marrow. — The marrow in children is soft, bright red in color, 
rich in cells and blood-vessels. In middle life there is an increase in 
fatty tissue, giving a yellow or yellow-red color of oily lustre, while in 
old age it atrophies, becoming gelatinous, with clear mucinous fluid, 
and there is a diminution of fat and a decrease in the number of cells 
present. This atrophy may follow chronic emphysema, phthisis, 
chronic disease of the kidney, or starvation. Lymphoid marrow is 
gray red or dark red, according to the amount of blood it contains. 
In pernicious anaemia the marrow of the long bones resembles rasp- 
berry jelly, while in leukaemia it has a flesh-pink to a gray-yellow color, 
like that of pus. Fatty degeneration occurs in the cells and capillaries 
of the marrow, sometimes with necrotic foci, in cases of typhoid, 
typhus, and relapsing fever. 

In osteomyelitis there is often a purulent inflammation, frequently 
complicated by transformation of the marrow into a vivid red, tough, 
fibrinous material, and with effusion into the cavity of a joint. 
Necrotic changes in the bone follow. Hypertrophy of the marrow- 
cells is seen in oligaemia, leukaemia, chronic pulmonary tuberculosis, 
chronic suppurative osteitis, cancerous cachexia, typhoid fever, croup- 
ous pneumonia, septic affections, acute endocarditis, and smallpox; 
while hypertrophy of the fatty tissue occurs in cases of general atrophy 
of the skeleton, sometimes involving the entire bone. 



2 68 POST-MOK I T.M I- XAMINATIONS 

Necrosis.— Necrosis arises as the result of shutting off of the 
blood-supply. It follows infective embolus, injury, poisoning, as from 
phosphorus, and as a sequela of scrofula and the infective fevers. 
Caries, necrosis superficialis, or erosion is, as a rule, circumscribed, but 
may be diffuse or phagedenic. It occurs in the cancellous extremities 
of a bone, usually in the tibia, femur, humerus, phalanges, skull, lower 
jaw, clavicle, and ulna, and affects the joints secondarily. It is always 
associated with periostitis, osteitis, or osteomyelitis. It is generally 
dry and anaemic, but in cases of sudden onset may be moist. The 
bone is ulcerated or worm-eaten in appearance, with numerous hollows 
or cavities. It is porous, very fragile, and of a dirty-yellow, dark-gray, 
or brown color. The surrounding bone is usually indurated and hard, 
except in strumous cases, where it is converted into a mass of fungous 
granulations. The compact substance is softer and the marrow spleni- 
fied. Dead bone may be thrown off as an exfoliation or as a seques- 
trum. Panaricium, or felon, is one of the most common forms of 
periosteal necrosis, the digital skin having been injured or infected. 
Diffuse necrosis, necrosis centralis, usually attacks the shaft. There 
may be caries of the superficial bone with a narrow channel leading 
down to a focus, or an abscess in the centre (chronic sinuous abscess), 
or it may be entirely internal. Abscesses are most common in the 
articular extremities, but may occur anywhere. Swelling of the skin 
and periosteum always accompanies necrosis. The periosteum may 
retain its vitality, producing a sheath of new bone around the seques- 
trum, the involucrum, through which holes (cloacae) form for the 
discharge of dead bone or pus ; or the sequestrum may be surrounded 
by old bone or by exudate from the inflamed periosteum, the pus 
making its way through the thickened periosteum and discharging on 
the surface through several fistulse or sinuses. Phosphorus necrosis, a 
purulent periostitis, attacks especially the jaw-bone, rarely the other 
bones of the face. At first there is a slight periosteal inflammation, 
then proliferation with formation of new bone, the maxilla becoming 
thick and sclerotic; later, suppuration leads to necrosis and exfoliation, 
at times destroying the entire bone. The infective granulomata, tuber- 
culosis, syphilis, leprosy, glanders, and actinomyces, produce chronic 
inflammations with deposition of osteophytes. The resulting necrosis 
is described under these diseases. 

Orthopaedic Deformities. — Genu valgum (knock-knee), a uni- 
lateral or bilateral displacement at the knee-joint, occurs in cases of 



BONES AND JOINTS 269 

rickets or in men who have lived laborious lives. The external articu- 
lar surface of the tibia or femur is retarded in its growth or depressed, 
so that these bones form with each other an obtuse angle. This may 
be associated with separation of the epiphysis, caries of the external 
condyle of the femur, or arthritis deformans. 

Club-hand, hallux valgus, club-foot, talipes varus, talipes valgus, 
talipes equinus, talipes calcaneus, talipes cavus, and talipes planus are, 
as a rule, due to perverted development of tendons. 

Contractures are associated with poliomyelitis, caries of the spine, 
trauma of the cord or peripheral nerves. They are the result of fixa- 
tion of a joint in a deformed position, the character depending upon 
the group of muscles paralyzed. Dupuytren contracture is a scar-like 
contraction with fingers flexed, due to trauma, rheumatism, or gout, 
affecting the palmar fascia. Small, hard, nodular fibromas are found 
along the course of the contraction. Late in the disease the skin is 
affected. 

Spinal curvatures are associated with pleural effusion, large tumors, 
unilateral contraction of the thorax, cirrhosis of the lungs, oblique 
fixation of the pelvis, rickets, tuberculosis, weakness of the muscles, 
occupation, etc. According to Bradford and Lovett, scoliosis, or lateral 
curvature, is most common in the thoracic region, usually to the right, 
with compensatory curve, in the lumbar region, to the left. Kyphosis 
may be a rotated lateral deviation or a result of disease, as tuberculosis. 
It forms a posterior protrusion of the vertebral spines ; if due to rota- 
tion, it is usually to the convex side. The vertebrae become wedge- 
shaped. Ossification of the ligaments is at times found. Lordosis is 
always associated as a compensatory curve. Synostosis, or ossification 
in a situation not normally ossified until advanced life, causes a marked 
deformity, especially of the pelvis, shortening in the base of the skull, 
craniostenosis, microcephalia, etc., and depressions of the bridge of 
the nose. 

Osteitis is almost invariably associated with periostitis. It may 
follow trauma, such as fracture, amputation, and gunshot wounds ; or 
infections, as pyaemia, scarlatina, measles, typhoid and relapsing fever, 
dysentery, smallpox, mumps, gonorrhoea, and acute articular rheuma- 
tism. Four forms of osteitis exist: (1) Rarefying (osteoporosis), a 
chronic form associated with wounds, syphilis, or tuberculosis, which 
consists in resorption of the spongy bone, with the formation of cavern- 
ous excavations. (2) Osteosclerosis, a reparative reaction, occurs in 



270 1> °^ T MORTEM EXAMINATIONS 

the same diseases and consists in the eburnation of the entire bone. 
(3) Osteoarthropathies (hyperplastic osteitis), associated with 
chronic tuberculous lung diseases, involves the terminal phalanges, 
which are swollen like drum-sticks, with their articular ends irregularly 
thickened ; it is also seen in rhachitis, osteomalacia, and osteitis de- 
formans. (4) Osteitis caseosa is always tuberculous. Purulent osteitis 
may follow typhoid, scarlatina, measles, and pyaemia, and is usually 
due to a secondary staphylococcic or streptococcic infection. It arises 
spontaneously in the femur and tibia; it is in almost every case asso- 
ciated with osteomyelitis, and at times with gangrene. 

In osteitis deformans we have an inflammatory disease of old age, 
consisting in a wide-spread absorption of the bone and the deposition 
of new bone. It may be limited to the femur, cranial bones, or spine, 
or involve the greater part of the skeleton. The resorption is marked 
in the cancellous and cortical regions, where the osseous trabecular 
may be replaced by gelatinous or fibrous tissue. This softening allows 
the long bones to bend at abrupt angles and gives rise to many deformi- 
ties, of which kyphosis is the most frequent. Cysts are often found. 
The deposition of new bone, which is especially seen in the skull, starts 
from the periosteum and from the marrow, causing thickenings of the 
bone. 

Osteomalacia. — Osteomalacia (mollities ossium) is a rare dis- 
ease, occurring especially in pregnancy, and is characterized by a rapid 
and general resorption of the inorganic salts, advancing from the 
centre outward and including all except a thin layer next to the peri- 
osteum. The marrow is increased and splenified, or replaced by a dark 
semifluid material. On section, the spaces contain a reddish gelatinous 
mass, which later becomes yellow and fatty. Cysts containing a clear, 
turbid, or hemorrhagic fluid have been seen in the interior of the 
bones. The bones are very light, bend and break readily, or may even 
be cut with a knife. Fractures are commonly multiple, occur spon- 
taneously or from very slight injury, and tend to repair, even in the 
activi >f the disease, the callus, however, remaining free from 

bone salts. At first the disease is limited to the pelvis; later the entire 
skeleton may be involved. In the so-called non-puerperal form the 
disease starts in the spongy bones of the vertebrae and thorax, extend- 
ing to the extremities "and finally even to the cranium. The sacrum 
is pushed downward by the weight of the body and the acetabula 
upward and inward by the femora, producing a characteristic pelvic 



BOXES AND JOINTS 2/1 

deformity. The disease is associated with general cachexia and often 
with pneumonia. 

Periostitis. — The normal periosteum presents a yellowish-gray 
color, while in suppuration it is distinctly yellow. It may be raised or 
inflamed by traumatism, perforation of compound fracture, abscesses, 
tumors, infectious granulomata, or extension of inflammation from 
neighboring structures. Blood under the periosteum, particularly near 
the epiphysis, is seen in children with Barlow's disease. Simple acute 
inflammation, usually local, produces a reddening, thickening, and a 
greater adherence of the periosteum to the bone. Suppurative perios- 
titis, generally associated with osteomyelitis, affects growing bones, 
and is rare after the union of the epiphyses. The exudate, or the 
hemorrhage beneath the periosteum, rapidly separates the membrane 
from the bone, causing stretching, occlusion, or thrombosis of the 
blood-vessels passing into the bone; hence necrosis of the superficial 
osseous layers results. Pyaemia and infective fat embolism may occur 
before the abscess is opened. A diffuse form, attacking the long bones 
in those presenting a strumous diathesis, often ends in a rapid sup- 
puration. 

Fibrinous, ossifying, or productive inflammation follows chronic 
inflammation of the joints, syphilis, rickets, and tuberculosis, and re- 
sults in osteoses, or bony thickenings. The periosteum is hardened, and 
a projecting node is formed beneath it, which may become fibrous or 
calcified (periostitis ossificans). This calcification begins as a vertical 
process at the surface of the bone, at first distinguishable from the old 
tissue, but later blended with it. In syphilis the subperiosteal nodes 
show a marked tendency to suppurate, and in rare cases suppuration 
occurs, but due to other causes, producing a malignant purulent perios- 
titis. Typhoid bacilli have been recovered from these cases. Albu- 
minous periostitis, a mild inflammation with a ropy, albuminous exu- 
date, is found only in the bones of the young. Tuberculous periostitis 
also occurs, most often in young patients, and has more or less sharply 
defined granulomatous foci, containing tubercles which become caseous 
and soften, and give rise to peripheral caries, sacculated cold abscesses, 
consecutive abscesses, sinuses, or fistulous tracts. The caseous nodes 
are surrounded by a zone of induration and granulations, which may 
be so luxuriant that they form mushroom-like -excrescences over the 
external orifice of the sinus. Simultaneous with increase of the caries 
there are proliferation of the periosteum and the formation of con- 



POST-MORTEM KXAMINATIONS 

siderable new bone. This is usually absent in the cranial bones, where 
resorption alone more often occurs. 

Rhachitis. — RhachitiSj or rickets, is a constitutional disease of 
childhood, characterized by alterations in the conversion of cartilage 
into imperfect osseous structure. Congenital rickets is rare, the so- 
called fetal rickets being merely a disturbance of growth closely resem- 
bling myxcedema, Rhachitic changes affect both the periosteal and 
medullary aspects of the long bones, especially between the shaft and 
the epiphysis, where a soft and irregular zone of proliferation, 5 or 10 
millimetres thick, is found. The bony tissue is softer and more vascu- 
lar than normal ; the marrow, wider and darker in color. The perios- 
teum strips off easily, revealing a spongy tissue which looks like decal- 
cified bone. Large osteoid formations occur under the periosteum at 
the insertions of the tendons and aponeuroses. The shafts of the long 
bones are usually bent and shortened and the short bones flattened. 
The cranial bones are thin and atrophied at the sites of pressure 
(cranio-tabes) ; the frontal and parietal bones often have flattened 
swellings, and the fontanelles remain so large that the head suggests 
hydrocephalus. A swelling may occur around the hip, simulating 
coxalgia. Associated with the bone lesions are anaemia, enlarged 
spleen, changes in the liver, muscular atrophy, and catarrhal inflamma- 
tion of the mucous membranes, especially of the intestines and respira- 
tory tract. The lungs and heart often present changes due to the 
deformity of the chest. Dentition is delayed. After the active stage 
of the disease the bones become very hard, heavy, and deformed. 

Tendons, Sheaths, and Bursas. — Acute tenosynovitis, simple or 
hematogenous, results from wounds, bruises, strains, or excessive exer- 
cise. Gonococci, pneumococci, or pus cocci infect the tendons usually 
of the dorsum of the hand, producing a purulent exudate, which shows 
a marked tendency to burrow between the sheath and the tendon, 
sometimes for considerable distances. In the dry form deposits of 
fibrin are found upon the inner surfaces of the sheath, giving rise to a 
nibbing or creaking sensation. The tendon is cloudy and swollen, the 
intervascular substance often suppurating or necrotic. Chronic teno- 
synovitis is generally gouty or rheumatic or the result of healing 
wounds. Calcareous deposits or gouty urates are particularly common 
in this form, and may cause necrosis, inflammation, or the formation 
of new fibrous tissue. Tuberculous tenosynovitis occurs in the walls 
of the sheath, with exudation. In advanced stages there may be 



BOXES AND JOINTS 273 

fungous granulations on the tendon. Tubercle bacillus may be found 
in the arborescent lipoma, a papillomatous, fatty outgrowth of the 
synovial lining, it being a debated question as to whether or not this 
organism causes the lesion. Hygroma or ganglion, due to chronic 
irritation, is a cystic mass which contains rice-like bodies in a serous 
fluid beneath the sheath of the tendon. 

Acute bursitis, acute hygroma, is a fluctuating tumor with serous, 
serofibrinous, or purulent exudate, the result of injury or haemato- 
genous infection. The walls are generally thin, but may be greatly 
thickened. In the chronic form, hygroma, hydrops bursarum, or house- 
maid's knee, the contents, in the early stages, are mucilaginous and 
viscid ; later, thin and limpid. Loose bodies are frequently found in 
these cysts. Tubercles may develop in the walls of the sac, associated 
with serous effusion, or the walls may become thickened and per- 
meated by fungous granulomatous masses which may undergo caseous 
degeneration. A ganglion is a round, oval, or lobulate cyst, varying 
in size from that of a pea to a pigeon's egg, and containing a reddish- 
yellow crystalline jelly or colloid material, probably the result of a 
recurring slight injury. It appears on the dorsal aspect of the inter- 
carpal joints. 

Tumors, Cysts, Parasites, etc. — True osseous tumors occur, 
which may be primary or secondary, myelogenic or periosteal. Oste- 
oma, exostosis, osteophytes, and enostosis are found, the latter arising 
from the periosteum or cartilage, during the period of growth at the di- 
aphyses of the long bones. Two kinds of osteoma are seen, — the can- 
cellous, or spongy, and the compact osteoma. On the skull they are 
usually small, round, conical, or mushroom-shaped. Chondromata 
usually arise from congenital, malplaced islands of cartilaginous tissue, 
though often not until late in life, and are found especially in the 
hands and feet of children and young adults, sometimes producing 
marked and grotesque deformities. They are nodose or tuberous ex- 
crescences which, especially on the scapulae, long bones, or ribs, reach 
considerable size. They may soften and form bone cysts. The mye- 
logenous are at first covered with a shell of- bone. Cartilaginous 
t from the epiphysis, as long or* rounded bony projec- 
tions, the apex or a greater part of their surface being covered with 
cartilage. These new growths undergo fatty, calcareous, and mucoid 
degeneration. Lipomata and angiomata are rare. Fibromata, nodular 
and highly vascular growths, occur on the facial and cranial bones and 



,-, POST-MORTEM EXAMINATIONS 

in the buccal and nasal cavities. A more rare tumor is the encapsulated 
myxoma, which arises simultaneously in the periosteum and marrow, 
the myelogenous form having no capsule and destroying the bone 
rapidly. Both varieties give rise to cysts, single or multiple. The 
sarcoma is the most common primary tumor, and the cells comprising 
it may be round, spindle-shaped, or giant-celled. It is often telangiec- 
tatic. The myelogenous sarcoma, usually occurring in the epiphysis 
of the tibia, humerus, etc., is, even until it reaches considerable size, 
covered with a bony shell, which may fracture spontaneously. On 
section, a milky fluid may exude. Periosteal sarcomata occur any- 
where and are generally mixed tumors. A special variety, chloroma, 
green and yellow in color, is seen in the facial and cranial bones. Car- 
cinoma is always secondary and is usually due to direct extension; it 
is seen in the skull, sternum, and ribs, where it forms either a circum- 
scribed node • or diffuse infiltration and is always accompanied by 
lacunar resorption. 

Cysts arise from lacunar atrophy, osteomalacia, disintegration, or 
excessive resorption. They are common on the alveolar processes of 
the upper or lower jaws, associated with enlarged and tortuous veins, 
and on the clavicle, usually connected with some solid tumor. A turbid 
or hemorrhagic fluid exudes on section. 1 

The Echinococcus is the most common parasite. It occurs in the 
long, pelvic, cranial, and vertebral bones as a single sac or as internal 
or external daughter cysts. There are always associated some resorp- 
tion and atrophy of the affected bone, and there may be distention, 
inflation, or spontaneous fracture. Cystic ercus is very rare. 

Aneurisms are generally anastomotic, but primary aneurism may 
occur, usually in the cancellated tissue of the head of the tibia, asso- 
ciated with absorption of the compact bone and periosteum. Hcema- 
tomata are occasionally produced by hemorrhage following trauma or 
rupture of a softening tumor. 

1 For a description of the benign dentigerous cysts of bones see Bloodgood, Jr. 
Amer. Med. Assoc, Oct. 15, 1904. 



CHAPTER XVIII 

POST-MORTEM EXAMINATIONS OF THE NEW-BORN 1 

In performing a postmortem on a child it is sometimes advanta- 
geous to remove the viscera en masse, scissors being largely used for 
this purpose in place of the knife, even to the cutting of the clavicles 
in their central part. In France evisceration is done quite frequently 
in the adult, and has the advantage of saving time by permitting the 
removal of the spinal cord while the thoracic and abdominal organs 
are being examined both from behind and in front. To practise evis- 
ceration the trachea and oesophagus are twice tied as high up as prac- 
ticable, divided between the ligatures, and the lower portion then ele- 
vated with the free hand. All the posterior attachments are cut as 
close as possible to the vertebral column until the diaphragm is reached. 
The cervical and thoracic organs are then brought out of the body 
and laid over the opposite costal margin to the side upon which the 
operator next works. The diaphragm is now excised laterally and 
posteriorly, adhesions being severed with the knife as before. It is 
well to pull from below upon the liver, stomach, and spleen, so that 
these organs will not be injured by the manipulations. The crura 
being cut loose, the diaphragm is free. The posterior peritoneum 
having been already incised by the removal of the diaphragm, the kid- 
neys are readily found from above, and when removed the psoas 
muscles come prominently into view. The common iliac vessels, round 
ligaments, etc., are next incised. Two ligatures are now applied to 
the rectum, which is then divided between them. When everything 
which holds the abdominal organs in place has been loosened with the 
hand, the organs of both the thorax and the abdomen can be readily 
removed, leaving only the bladder and organs of generation in situ; 
these may be excised later, in the same manner as that described for 
the adult on page 15; or, by means of the incisions there given, re- 
moved while still attached to the other abdominal viscera. The cervico- 
thoracic abdominal cavity is then to be carefully inspected. 

The body of a child thus disembowelled can be kept for a long 
time, especially if the thoracic and abdominal cavities are packed with 

1 For additional information see pages 243, 344, and 358. 

275 



276 POST-MORTEM EXAMINATIONS 

a mixture of equal parts of bran and salt to which a little white arsenic 
lias hern added. The cadaver may then advantageously be surrounded 
with cotton and a circular bandage applied to the chest and thorax. 
Parental consenl to the performance of an autopsy may sometimes be 
obtained by giving .assurance of the preservation of the body by this 
nmde of procedure. 

In the child there will at once be noticed the large size of the liver, 
appendix, and adrenals; also the perpendicular situation of the stom- 
ach, it being more difficult to distinguish the greater and lesser curva- 
tures than in the adult. The dissection of the cardiac plexus should 
always be made after diphtheria and other contagious diseases attended 
with cardiac failure. This examination also includes the pneumo- 
gastrics and the cervical sympathetics. Wrisberg's ganglion is found 
by looking carefully in the region of the arch of the aorta, the right 
branch of the pulmonary artery, and the fibrous remnants of the ductus 
Botalli. \Yalckhoff believes that the expansion of the lungs changes 
the position of the heart to such an extent that the arterial canal is at 
once twisted, thus stopping the circulation through it. The unex- 
panded lungs are of firm consistence, do not crepitate, and do not 
cover the anterior surface of the heart. The color is a brownish slate. 
The expanded lungs are of light rose tint, somewhat blood-stained, 
except where the bluish spots of fetal atelectasis persist. The methods 
of examining the umbilical vessels and the ductus arteriosus are readily 
seen by referring to Figs. 154 and 155 respectively. Study with care 
the point of insertion of the gelatin of Wharton to the circular fold 
of the skin at the umbilicus in a new-born babe. 

The removal of the child's brain is more difficult than that of an 
adult, because, first, it is much softer, and, second, the dura is normally 
adherent to the cranium. But it is easier in one respect, — the bones 
and sutures are not ossified. In a new-born child the brain is so soft 
that its removal without injury is almost impossible. In such cases 
it is advisable to lay the body for a short time on ice sprinkled with 
salt, in order that the brain may become firmer by the consequent low- 
ering of the temperature. By another method — and it is the one from 
which I have obtained the best results — the child is placed in a large 

in or tub containing a strong solution of common salt (about half 
a bucketful to four or five times this amount of water) and held steady 
by an assistant while the brain is removed by operating beneath the 
surface of the liquid. As brine of the above strength has a specific 




Fig. 154. — Examination of the umbilical vessels. (After Nauwerck.) 



Right pulmonary artery 




Left pulmonary artery 



Pulmonary valves 



Papillary muscle and tricuspid valve 



•.'tmination of the ductus arteriosus. The sound is represented as introduced into the ductus 
arteriosus Botalli ; this duct usually < loses about the fourth flay after birth. (After Nauwerck. ) 




tnoval of the spina] cord of a child. 




a > = 
5. o = 





Fig. 159.— Method of examining nasal cavities, antrum of Highmore, etc. By means 
of a knife the uppermost mucous membrane between the lip and the superior maxilla is 
incised, the upper lip being elevated with the left hand during the incision. Vertical 
sawing is now done in the median line, and the tooth extracted at the point where the 
lateral sawing is to take place. The bone-forceps readily bring the desired portion of 
bone away, or it can be loosened by means of a chisel. 




Fig. 160.— Appearance of the part after removal of a portion of the superior maxilla for 
the purpose of examining the nasal cavities, antrum of Highmore, etc. 



POST-MORTEM EXAMINATIONS OF THE NEW-BORN 2 yy 

gravity slightly greater than that of the cerebral substance, it affords 
a more general and even support in the subsequent manipulation, thus 
lessening the liability of damage in the removal of the brain. 

The method in detail is as follows : The scalp is incised across the 
vertex and the flaps are turned forward and backward as in the adult. 
With scissors having well-rounded points the sutures and dura are 
cut through well down to the base of the skull. The five flaps thus 
formed are pulled outward and, if necessary, cut partly across their 
base with strong scissors. While the brain is being removed the body 
should preferably be held in the salt solution. Begin by removing the 
falx cerebri and longitudinal sinus, then the frontal lobes, olfactory 
bulbs, etc., in the usual order. When the tentorium and falx are cut 
through, the brain can be pushed out into the solution, where it will 
float. If it be desired to harden the brain, it is well to place a jar of 
Mulleins or other hardening fluid in the brine and under the brain as 
it floats therein, care being taken in the transfer to allow as little as 
possible of the salt solution to enter the jar, though the fluid should 
afterwards be changed for a fresh supply. 

The spinal cord may be removed from the body of a baby with 
scissors alone, as the parts are easily cut through. The lines for the 
incisions through the skin and the vertebrae are made in the same 
manner as in the adult, but neither knife nor saw is required, the scissors 
being strong enough to penetrate easily the soft bony structures of the 
vertebral column in a child under fifteen months of age. (Fig. 156.) 
In babes the spinal cord is relatively much more firm than the brain. 

In autopsies on babes suspected of being the victims of hereditary 
syphilis it is often important to look for the fatty changes produced 
by that disease at the junction of the cartilage and the bone in the 
femur. For this purpose a longitudinal incision is made directly over 
the head of the os femoris and the soft parts are dissected until the bone 
is reached. The ligaments are then incised and the head is disarticu- 
lated. The shaft is held by the left hand securely wrapped in a towel 
while a perpendicular incision through the cartilaginous head is made 
down to the bone; should this be much ossified, the incision may be 
continued with a saw. After sawing for about two inches, a knife is 
introduced and one segment is broken off. The presence of a yellowish 
area of fatty degeneration, more conspicuous in the osseous portion 
than in the cartilage, shows an interference in the nutrition of the part, 
quite characteristic of hereditary syphilis. (Figs. 157 and 158.) 



278 POST-MORTEM KXAMINATIONS 

The centre of ossification of the lower epiphysis of the femur is 
present at the end o\ the ninth lunar month of intra-uterine life. In 
over 700 t'nll-tcnn infants examined by Vibert and Liman it was 
found to be absent in only sixteen cases. To determine the presence 
or absence of Beclard's sign (presence of the centre of ossification in 
the femur) the knee is forcibly flexed, and the epiphyseal cartilage of 
the femur is cut in thin sections perpendicular to the axis of the bone 
until the greatest diameter of the femoral osseous centre is found, 
which in a child at term will measure from a half to five millimetres 
across, its red color affording a striking contrast to the gray' cartilage, 
except where putrefactive changes are far advanced. The ossific centre 
of the tarsal cuboid bone is still more reliable in determining maturity, 
as this centre appears at the last month of fetal life. Another sign 
of importance in a full-term child is the presence of eight separate 
small dental compartments in the inferior maxillary bone, four on 
each side of the median line, and a large space towards the ramus 
which has not yet had the partitions divided off, though an attempt 
at their formation may often be seen. To determine if the child be 
viable the osseous centre of the os calcis should be examined, as this is 
first found between the one hundred and ninety-sixth and the two 
hundred and tenth day of fetal life. 

After a careful study of the urine of the new-born, Sabrazes 1 
concludes that the secretion of the fetal kidneys possesses hemolytic 
properties and is poor in chlorides and phosphates. Some authorities 
find no phosphates until after two complete days of extra-uterine 
existence. In the renal tubules are found during the first week of 
life considerable quantities of precipitated sodium urates, causing in 
the pyramids yellowish-white lines which converge towards the apex 
of the papillae. These are supposed to prove that the infant was born 
alive. If a child was born before term, meconium is found alone in 
the small intestine, but if born at term, it is found in the large intestine. 
The kidneys are lobular, as in ruminants. 

The latest investigations lead to the conclusion that puerperal 
eclampsia arises from a defective excretory power of the mother, 
usually referable to the kidneys, but that the actual toxin is a fetal 
product, the added stress of which upon the defective eliminating 
powers of the mother precipitates the eclamptic attack. Raubitschek 2 

1 Hebd. des sciences med., October 5, 1902. 

' Z. f. Hcilkundc, vol. xxv, no. 1, p. 16; abs., Amcr. Med., March 26, 1904. 



POST-MORTEM EXAMINATIONS OF THE NEW-BORN 279 

believes that the secretion (Hexenmilch) frequently found in the 
mammary glands of the new-born is the result of a necrosis and the 
separation of epithelial cells in the acini and ducts of these glands, 
which are thus shown to be at this stage analogous to the sebaceous 
glands. The secretion of colostrum immediately preceding lactation 
in the puerperium is of similar origin. 

Blummer 1 considers the status lymphaticus to be a definite patho- 
logic entity, probably associated with, if not due to, a condition of 
intermittent lymphotoxoemia, and at times capable of playing an im- 
portant role in sudden death, fatal anaesthesia, and infection. In some 
cases sudden death is undoubtedly mechanical and due to asphyxia 
caused by the enlarged thymus pressing on the trachea. 

The following two examples of the many which have come under 
my personal observation show the necessity of constant vigilance on 
the part of the practising physician in order that he may draw correct 
conclusions from the pathologic data presented to his view. Two 
days after its birth a babe came upon the post-mortem table of one 
of the hospitals with which I was connected some years ago. The 
autopsy revealed a completely imperforate rectum, the anus likewise 
being imperforate. The physician in charge had ordered immediately 
after birth that a glycerin suppository should be administered morning 
and evening. The nurse reported each time upon the hospital records 
the carrying out of the order! 2 In 1896 there came by train to 
Philadelphia a hard-working colored woman who was about five 
months pregnant. Feeling her labor pains coming on she took a cab 
at the Broad Street Station, and was driven to one of our large hos- 
pitals, where she was duly delivered of a dead child. The cabman 
returned to his post, seeking more work. Upon being again employed 
a five-months' colored fcetus was found on the floor of the carriage. 
At the coroner's inquest the mother swore that she was unaware of 
the fact that she had given birth to the child while in the carriage 
and that no abortion had been performed upon her person. She con- 
sidered the premature labor as being due to hard work. At the hos- 
pital the placenta had not been critically examined, the existence, there- 
fore, of a twin pregnancy not being established at the time of the 
delivery of the dead foetus. 3 

1 Johns Hopkins Bulletin, October, 1903. 

tell, Annals of Gyncec. and Pediatry, September, 1893. p. 759. 
3 Cattell, Int. Med. Mag., February, 1897, p. 80. 



CHAPTER XIX 

RESTRICTED POST-MORTEM EXAMINATIONS 

In case permission to open the thorax is refused, the diaphragm 
may be severed from its anterior attachments, and the lungs, the heart, 
and even the tongue and adjacent parts may be removed en masse 
through an abdominal incision or a laparotomy wound. 

Should the avoidance of visible mutilation be imperative, it is pos- 
sible to examine and, if necessary, to remove both the abdominal and 
thoracic viscera through the rectum or perineum in males or through 
these parts and the vagina in females. In the male this procedure is 
performed in the following manner: 1 

The body is placed on the back, with the buttocks very near the 
end of the table and the thighs widely separated and flexed upon the 
body. The scrotum is then well drawn up, and an incision is made 
from the perineo-scrotal junction to the margin of the anus and down 
to the bulb. The knife is carried around this and through the sub- 
jacent tissue to the pelvic fascia underlying the vesicorectal pouch, 
without injuring the bladder or rectum. The left arm being bared to 
the shoulder, the hand is introduced through the incision, and gradually 
forced up between the parietal peritoneum and the rectus muscles to 
the diaphragm. The peritoneum may be opened, but the intestines will 
invest the hand like a tightly fitting glove and make the manipulation 
more difficult. If unable to perforate the diaphragm with the fingers, 
a scalpel may be carried up, with the blade flat against the index-finger, 
and a nick made in the muscle, the knife being then withdrawn and the 
opening enlarged with the fingers. The lungs may be examined by 
palpation, any adhesions broken up, and the organs dragged into the 
abdominal cavity, the roots being severed with a knife, after which 
they may be removed. The heart can be examined in a similar manner, 
except that, before it can be moved very far, scissors or a knife will be 
nece -ever the large vessels. The kidneys, adrenals, spleen, 

stomach, etc., may be removed in this manner, but the liver must gen- 
erally be divided into its lobes in order to get it through the incision. 
The organs are examined in the usual manner and returned to the 
body; some wads of oakum may then be pushed into the abdominal 
cavity and the perineal incision very carefully closed by hidden sutures. 

1 H. A. Kelly, Medical News, June 30, 1883. 



RESTRICTED POST-MORTEM EXAMINATIONS 2 8l 

It is also possible to make the examination through the rectum, but the 
sphincter is left dilated and gaping, presenting a much more con- 
spicuous and unsightly appearance than the perineal incision. 



This method is most difficult of accomplishment when the operator's 
arm measures more than ten or eleven inches around the biceps, espe- 
cially in subjects of only average size. The work is very arduous, 
because of the strained and cramped position which the hand and arm 
must assume in order to pass the promontory of the sacrum. Coplin 
suggests the use of the photographer's thimble in tearing the tissues 
within the abdominal cavity. 

Access to the interior of the trunk may readily be had from the 
dorsum by making a longitudinal incision to one side of the spinal 
column and sawing the ribs close to their vertebral attachments. When 
the examination is made through the vagina, an oval incision such 
as is described on page 183 may be made, or a vaginal hysterectomy 
may first be performed (Figs. 101 to 109 inclusive). 

The brain may be removed almost intact (in two or three pieces) 
by making a transverse four-inch incision across the fifth cervical ver- 
tebra, dissecting up the soft tissues, and cutting a V-shaped segment 
out of the occipital bone by introducing a saw through the foramen 
magnum and sawing towards the ears and then across transversely. 
(Fig. 143, E A F.) A rapid, but not scientific, method of diagnosing 
hemorrhage, which also permits of the removal of the brain in small 
pieces, is referred to on p. 233. 

An examination of the bones of the face is sometimes desirable, but 
the circumstances and conditions under which it may be required are 
so variable that the method must be left entirely to the judgment of 
the operator. Disfigurement is so readily noticed that nothing further 
than a superficial examination should be attempted without the per- 
mission of those interested. The simplest and most unobjectionable 
method of procedure is to introduce the knife through an incision pre- 
viously made from the ear to the neck and dissect subcutaneously the 
tissue investing the bony structures. If the bones of the face are to 
be removed, it may be necessary to make a transverse incision, the point 
of election being the furrow between the inferior maxilla and the neck. 

If the oral cavity must be examined through the orifice of the mouth 
after rigor mortis has set in, the rigidity may be overcome by placing 
towels soaked with hot water over the muscles of the jaw. Such appli- 



2 8 2 IM >ST MOK IT.M KXAMINATIONS 

cat inns repeated for about five minutes usually suffice. Do not use a 
chisel to pry the jaws apart, as is sometimes recommended, because of 
the danger of breaking the teeth or knocking them out. As the rigidity 
rarely returns, it is advisable at the end of the examination to close the 
mouth with a few sutures through the mucous membrane of the upper 
and lower lips. 

The nasal cavity may he exposed and examined by detaching with 
a knife the upper lip from the maxilla from within and then removing 
with a saw such portions of the superior jaw-bone as will afford room 
\ov inspection of the parts under consideration (Figs. 159, 160). By 
the removal of the eye the pituitary body, Gasserian ganglion, etc., are 
rendered easily accessible. Indeed, it is surprising what extensive dis- 
sections may be made in the region of the face and neck in the ways 
just mentioned, thus affording an opportunity for thorough digital 
examination of areas not open to ocular inspection. 



CHAPTER XX 

RESTORATION AND PRESERVATION OF THE BODY 

When the examination has been completed, the cavities of the body 
should be thoroughly sponged out, all blood and other fluids removed, 
and bleeding vessels tied to prevent leakage. The organs should then, 
as nearly as possible, be returned to their respective positions, and the 
cavities filled with dry bran, absorbent cotton, sawdust, sea-weed, or 
shavings, in sufficient quantity to restore the original contour of the 
body, covering the abdominal contents with old cloth or papers to pro- 
tect the under surface of the seam. The brain is generally put into the 
abdominal or thoracic cavity, owing to the great difficulty in returning 
it to the skull. If several postmortems be made at the same time and 
place, care should be taken to return the organs to the proper body, nor 
should a cadaver be used as a convenient receptacle for the disposal of 
specimens which are no longer of any use. In the case of a child a 
small bag may be packed with sand or sawdust so as to assume the 
shape of the brain and placed inside the calvarium; the brain itself, 
after dissection, is placed in the abdominal or thoracic cavity. It is 
unwise, however, to permit any member of the family to witness this 
procedure. 

In all private cases it is important to secure the skullcap in position, 
tc prevent the unsightly disfigurement produced when it slips after the 
scalp has been sutured. A number of efficient methods have been 
devised, but the one selected usually depends upon circumstances or 
upon ingenuity. The fossae of the skull as well as the calvarium may be 
filled with plaster of Paris, and while the plaster is still soft a short, 
stout stick of wood is pushed through into the foramen magnum, the 
upper end extending to the skullcap, which is then adjusted. When the 
plaster hardens, the calvarium is well fastened in good position. If in 
removing the skullcap the precaution is taken to crack at least a part 
of the inner table with the chisel and hammer, projecting pieces of bone 
are usually left, which interlock and hold the calvaria snugly in position 
when it is replaced. 1 If the edges of the temporalis have not been too 

1 Mallory and Wright, Pathological Technique. 

283 



»K I I M IXAM1NATI0NS 

badly lacerated, sutures may be passed through the muscle and fascia 
with very satisfactory result-. Small holes may be drilled in the skull 
and suture- passed through them, or a wide staple (or double-pointed 

carp. ay he used for the same purpose. Another method is to 

drive a small wire pin, or a wire nail with its head cut off, about half 
an inch long, half way into the diploe of the skull and insert the other 
end in a hole, made to correspond, in the calvarium. Two of these pins 
should he enough. Still another method is that described by Slee. 1 The 
posterior line i)i sawing, instead of stopping at the angle, is continued 
an inch or more into the temporal bone; a piece of ordinary roller 
bandage is then stretched across the skull and inserted in the saw-cut; 
the calvarium is replaced, the ends of the bandage are brought together 
«»ver the vault and securely sewed, pinned, or tied (Fig. 161). A ready 
and efficient method of my own for fixing the skullcap is to make in two 
i >r three places on the thickest portions of the skull vertical pencil-marks 
across the line of sawing and extending an inch above and below it, 
saw these for three-quarters of an inch or so, and into each pair of saw- 
cuts insert the ends of a thin double-wedge-shaped piece of iron or 
steel so made that it will be tightly pushed into place when the skullcap 
is affixed. Any portion projecting beyond the bone is hammered down. 
F 'i- another method see Fig. 162. 

If the vault of the cranium is to be retained by the physician 
and a substitute cannot be found, take a square piece of pasteboard 
about three millimetres thick (thinner for children) and soak it in 
warm water for a quarter of an hour, or until it is soft enough to be 
easily moulded over the skullcap. Having done this, cut the paste- 
board parallel to the edges of the saw-cuts and overriding them from 
ten to fifteen millimetres. Then fill the skull cavity with wadding 
or plaster of Paris. Remove the pasteboard from the skullcap just 

11 as it becomes so dry that when it is applied to the base of the 

skull the edges will adapt themselves to the border thereof. With a 
knife the edges of the pasteboard are cut obliquely, any folds which 

Formed therein are incised along their crests, one edge is tucked 
in under the other, and the surface smoothed by the use of the knife. 
Strong twine is hound twice around and the pasteboard thus securely 

ened to the base of the skull. The temporal muscle is drawn up- 
ward and the skinflaps stitched as is next described. (Nauwerck.) 

1 Medical News, December 31, 1892, p. 737. 













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" 










pp 










■Hj 










* 










^^ , 



Fig. 161. — Method of sewing up the body. 




Fig. 162. — Appearance of body after it has been sewed with base-ball stitch. The sewing has been done 
from above downward, and there is no puckering at the point of starting. 




FlG. 163. — Slee's method of fixing the skullcap. 




< 1. Author's method of holding skullcap in place. Four holes are drilled in the 
two to the right and left of the angle in the temporal bone and two in 
the iknlli :i[> just above the angle. Saw-cuts to hold the wire or string are made in the vertex, 
th< strintc being thrust in and out of the openings and tied at any convenient spot. 




Fig. 165. — Method of withdrawing blood from a body previous to its injection with an embalming 
fluid. A, trocar inserted into left auricle of the heart; B, stop-cock; C, exhaust valve; D, outlet valve 
for air ; E, syringe. The valve D is used when fluid is to be pumped into the body. 




Fig. 166. — Injection of body with embalming fluid. A, cannula inserted into brachial artery; B, tube 
going down to bottom of bottle containing embalming fluid ; C, hand-bulb and valve, by the use of which 
the fluid is forced through the arterial circulation. 



w 



Refrigerating room. ./, recording thermometer and middle tier of shelving; B and Z>, tiers of shelving; 
C, brine tank; E, pipes of refrigeration apparatus. 




G. 168.— Preparation of bodies after removal from refrigerating room. A, bath; B, air-condenser and injecting 
apparatus; C, pulley suspension apparatus ; D, exterior of refrigerator box; /<;, odorless excavator barrels. 



RESTORATION AND PRESERVATION OF THE BODY 285 

The skullcap being secured, the scalp is replaced and sutured with 
glover's or base-ball stitches, — i.e., those made by repeatedly passing 
the needle from within outward. By careful use of black or dark 
thread the incision may be so neatly closed as to escape even fairly 
close inspection. It sometimes happens that by stretching the skin 
becomes baggy. Should such be the case, a small portion of the hairy 
scalp parallel to the original incision across the vertex may be re- 
moved previous to the sewing. 

After the organs are returned, the sternum should be supported 
by paper, or, still better, by old linen. Bran and fine sawdust are very 
useful to fill in with, as they absorb the moisture. Oakum makes the 
sewing difficult. If the organs have been removed through the vagina 
or rectum, these outlets should be doubly sewed, some absorbent 
material having first been introduced to prevent leakage. 

A round stick or a piece of gas-pipe may be placed in the spinal 
canal after the removal of the cord, with the upper end pushed through 
the foramen magnum, especially if any of the vertebras have been 
taken away, and plaster of Paris may be poured in until the cavity- 
is well filled. An old cloth or some paper is then placed on top and 
the whole sewed together. The line of the incision may be covered 
with a strip of adhesive plaster. As in Gersung's method for the cor- 
rection of deformities, paraffin at a temperature of about 55 ° C. may 
be injected into the body in large quantities and before cooling be 
moulded into the proper shape. 

The abdominal incision is closed by sewing from the pubes to 
the sternum, passing the stitches from within outward, about three- 
eighths of an inch from the cut edges and about half an inch apart, 
alternating on the two sides so that each needle-hole on one side 
will be midway between two on the opposite side. The twine should 
be about half a millimetre thick. Both ends of the suture should be 
securely tied. For the closing stitch it is well to cut the thread near 
the needle, withdraw one end, and tie in a surgeon's knot. Roughly 
estimated, the thread required is twice the length of the incision to 
be closed. Carefully crowd in any extruding fascia and avoid pucker- 
ing of the part. (Figs. 163 and 164.) 

If the mouth has been opened, or any of the tongue removed with 
the structures of the neck, the lips may be held together by a few 
sutures passed through the oral mucous membrane. 

If any portions of bone have been excised, their place may be sup- 



jS() POST-MORTEM EXAMINATIONS 

plied by using a properly shaped piece of wood, which is held in 
on with sutures, wire, or strong cord, or by plaster of Paris. 

Lastly the body should be very carefully cleaned and returned to 
the place ami position in which it was found. 

The characteristic " post-mortem odor" is very persistent and de- 
fies all kinds of soap. It usually results from handling the intestines, 
and can best be removed by washing the hands with aromatic spirit 
of ammonia or, in the absence of that, by rubbing them with dry 
mustard and then washing with soap and water, or, still better, with 
some of the newer liquid antiseptic soaps. 

Ammonia or the aromatic spirit thereof will remove iodin stains, 
while carbol-fuchsin and other anilin stains yield to a weak solution 
of sodium hypobromite. 

Embalmed and Frozen Bodies. — Embalming may interfere with 
the work of the pathologist, the bacteriologist, and the toxicologist. 
Fortunately, the old zinc, mercurial, and arsenical combinations have 
been very largely superseded by formalin, a much more desirable 
preparation, although it may irritate the eyes, deaden the sensibility 
of the finger tips, and even produce an eczema of the hands. Arterial 
embalming is at present more used by undertakers than any other 
method of preserving the body after death. It is usually practised by 
opening one of the superficial arteries, as the femoral, carotid, radial, 
or brachial, and injecting at least two quarts of fluid slowly into the 
vessel (arterial embalming). (Fig. 165.) It is customary among 
many undertakers to first aspirate the heart and remove as much 
blood as possible (Fig. 166), though this procedure is no longer of 
such importance as formerly, owing to the improvement in the pre- 
servative powers of the embalming fluids now in use. Removal of 
the contents of stomach and intestines is also sometimes practised and 
materially aids the preservation. 

Next in importance is cavity embalming or injection of preserving 
fluid into the three body cavities. In the abdomen, the instrument is 
thrust, preferably, through the umbilicus, so that the wound of en- 
trance will not be conspicuous, and efforts are then made to puncture 
the heart, lungs, intestines, liver, and other abdominal organs. The 
gas escapes, any blood exuding is withdrawn, and the fluid is after- 
wards injected, the stream being directed towards the liver. Some 
embalmers urge avoidance of any injury to enclosed viscera, and 
remove the contents per rectum. 



RESTORATION AND PRESERVATION OF THE BODY 2 8y 

The disadvantages of this method are : first, in cases of abortion 
with peritonitis there may be considerable difficulty in determining 
whether the openings were made before or after death; secondly, 
such punctures may also complicate matters by opening up abscess- 
cavities, cysts, aneurisms, etc. ; and thirdly, in cases of poisoning, 
besides allowing the stomach contents to escape, the fluid may contain 
the same substance as that which caused death. Even when formalin 
has been employed, as in the recent Haines case in New Jersey, the 
syringe may have been previously used for injecting an arsenical prepa- 
ration. 

The thorax is best filled by injecting the fluid through a long 
curved trocar passed down through an opening in the trachea. The 
fluid should first fill both lungs, and afterwards the trocar should be 
pushed down so that the point pierces the pleura, and these cavities are 
then to be filled with fluid. The brain cavity is best filled by passing a 
needle up the nose, breaking the cribriform plate, and then injecting 
the cerebrospinal cavities and the sinuses. Any excess of fluid passes 
through the jugular vein to thoracic organs. 

The trocar may be passed through the inner canthus of the eyes 
by the sphenoidal fissure, or through the foramen magnum, thence 
injecting the brain and cephalic cavity. Fluid may also be previously 
introduced by lumbar puncture. 1 These methods, though preserving 
the nervous tissue, are not as efficient as the arterial embalming for 
the preservation of the body and are apt to discolor or cause swelling 
around the face. 

Xauwerck employs: an injection-syringe having a capacity of 
five hundred cubic centimetres; long cannulas of different calibers, 
with pear-shaped ends and with stopcocks or, preferably, with double 
stopcocks; strong twine; scalpels, scissors, forceps, grooved director, 
haemostats, an aneurism-needle, and ordinary needles; basins and 
buckets ; several packages of absorbent cotton ; cloths and sponges ; 
and ten litres of a one per cent, watery solution of corrosive subli- 
mate, which may be kept in one-litre bottles. His method of em- 
balming is begun by exposing the lower part of the abdominal aorta 
and the two iliac arteries. Two ligatures are placed beneath the 
aorta, about two finger-breadths apart, and the aorta is obliquely 
incised to allow the entrance of the cannula, which is secured by 

1 Onuf, Med. Record, July 9, 1904. 



POST MOU I 'EM i:\AMINATIONS 

tying the distal ligature over it. The injection into the upper part 
of the body is then begun carefully and slowly, pausing occasionally 
when the counter-pressure becomes too great. About three litres 

injected, more or less, depending upon the appearance of swell- 
ing of the fare, seen first about the eyes and chin. The cannula is 
removed, both proximal and distal ligatures are tied, and the aorta 
is cut through. In like manner a litre of the solution is injected into 
each leg through the common iliac artery. A cannula with a double 
stopcock can be used to inject both the upper and lower parts of the 
1 ody at the same time. The mesentery is ligated, and the intestines, 
from the beginning of the jejunum to the end of the sigmoid flexure, 

removed, opened, washed out, and put in a one per cent, solution 
of bichloride o\ mercury, and later replaced in the abdominal cavity, 
wrapped in sublimated cotton, or, where practicable, disposed of by 
cremation. The stomach, duodenum, and rectum are cleaned out with 
sublimate solution and packed with sublimated cotton. The bladder, 
vagina, external ear, and nose are similarly treated. The abdominal 
cavity is carefully wiped with a cloth wrung out of the bichloride 
solution and dried, and the abdominal incision is sewed. The sur- 
face of the body, with the exception of the hair, is also wiped with the 
solution and dried. If this method fails, Nauwerck injects into the 
carotid and axillary arteries. 

I lewson * recommends the following injection for the preserva- 
tion of human bodies for the dissecting-room: 

K Sodium arsenate 2 kilogrammes. 

-ium nitrate 1 kilogramme. 

Carbolic acid 150 cubic centimetres. 

foiling water 7850 cubic centimetres. 

Boil until complete solution, then add 

Glycerin 2000 cubic centimetres. 

Formalin (40 per cent, solution) 100 to 150 cubic centimetres. 

Thymol, as much as will go into solution, a piece the size of the 
the thumb being sufficient for a carboy of solution. 

About two and one-half gallons of this fluid are introduced into an 
ry- -say the common carotid — by gravity, openings having pre- 
viously been made in the toes or in several of the veins if they be 
'■])<\c<\ with blood. After injection the body is thoroughly greased, 

1 Phila. Med. Jr., October 27, 1900; Amer. Med., February 27, 1904. 



RESTORATION AND PRESERVATION OF THE BODY 289 

covered with paper, bandaged, and placed in cold storage until wanted 
for dissection. 

Frozen bodies should not be thawed hastily by the addition of 
warm objects, but should be allowed to remain in a warm room for 
some twelve hours previous to the post-mortem examination. Figs. 
167 and 168 show the refrigeration room of the Medical Department of 
the University of Pennsylvania, planned by Dr. Holmes, in which when 
teaching in that institution I kept the cadavers used in illustrating 
my lectures. The bodies were removed during the afternoon pre- 
ceding the performance of the autopsy the next morning. At the Paris 
morgue the bodies are frozen at — 12 C. to — 14 C. immediately 
upon their arrival ; at the end of one day they are placed in a separate 
apartment having a temperature of — 4 C, so as to facilitate their 
thawing in fifteen to twenty hours. (Letulle. ) 

Death Mask. — In the making of a death mask about five pounds 
each of plaster of Paris and of modelling clay are employed. Nearly 
all of the clay is rolled out until it reaches thirty inches in length. 
The head is placed perpendicular to the body upon an old pillow, and 
then the face and any hairy portions which are to be included in the 
mask are thoroughly anointed with olive oil or liquid vaseline. Crum- 
pled towels or pieces of paper are now arranged so that when the 
potter's clay is entwined around the head it will be supported and pre- 
vent the liquid plaster of Paris from escaping. Any openings are now 
filled in with the remainder of the potter's clay, and the interior of 
the potter's clay anointed with olive oil. Two quarts of water are 
placed in a bowl and the plaster of Paris is slowly added, the whole 
being constantly stirred with a large spoon until of a gruel-like con- 
sistency, then more of the plaster of Paris is added until it begins 
to thicken, when it is immediately poured into the hollow cavity to 
secure the mould of the face. If the plaster of Paris is good it will 
set in about twenty minutes ; the potter's clay is removed, and the cast 
can be lifted in a single piece from the face. It is then carefully 
packed in cotton, removed to the laboratory, coated with mastic var- 
nish, and oiled. A plaster-of-Paris cast is now made of the mould in 
a similar manner, or the mould itself may be sent to an Italian worker 
in plaster, usually to be found in a city of any size. 



'9 



CHAPTER XXI 

DISEASES DUE TO MICRO-ORGANISMS, PARASITES, AND H^MATOZOA 

The number of diseases known to be due to vegetable and animal 
parasites is constantly on the increase, the study of tropical diseases 
especially having in recent years received marked attention and added 
much to our knowledge on this subject. The lesions which are pro- 
duced by these agencies and found post mortem are varied, though 
rarely characteristic, and require special bacteriologic and histologic 
training for their study and elucidation. 

Actinomycosis. — A chronic, infectious disease, which occurs most 
frequently in cattle (as "lumpy jaw" or "wooden tongue"), but is 
found also in man ; it is characterized by the formation of small 
nodules, which break down and infiltrate the surrounding tissue. The 
exciting cause, the Streptothrix actinomyces ( ray- fungus ) , is found in 
the form of yellowish opaque granules, — called sulphur balls, — which 
measure from one-half to two millimetres in diameter. When these 
masses are crushed and placed under the microscope, they give the 
appearance so beautifully depicted (in 1856) by Lebert in his Atlas. 
The organism is introduced into the body with food, often through the 
medium of carious teeth. In one case reported the patient had been 
accustomed to pick his teeth with a straw. The most common loca- 
tions of the lesions are: I. Alimentary canal. II. Lungs (lesions 
are usually unilateral), (a) Chronic bronchitis, (b) Miliary nodules 
formed by masses of fungi surrounded by granulation tissue, (c) 
These nodules may fuse, forming abscesses and finally cavities, (d) 
Bronchopneumonia. III. Heart, emboli and localized parenchymatous 
myocarditis. IV. Thorax, (a) Erosion of vertebrae. (&) Necrosis 
of ribs and sternum. V. Skin, (a) Subcutaneous abscesses, (b) 
Chronic ulceration, which may last for years. VI. Primary infections 
of the brain, liver, and vermiform appendix have been described. The 
characteristic primary lesion is a small nodule resembling that seen in 
an anatomical wart. Later there occurs, especially in the lower jaw, 
proliferation of cells into surrounding tissues similar to those seen in 
osteosarcoma; this is followed by suppuration. The abscesses are at 
first multiple, spherical, and discrete; later they coalesce and give a 



MICRO-ORGANISMAL DISEASES 291 

reticulated and honeycombed appearance to the part affected. Metas- 
tases may occur. 

Axthrax. — An acute, infectious, contagious disease, more com- 
mon in the lower animals than it is in man, caused by the Bacillus 
anthracis, and having for its characteristic lesion a pustule. Certain 
animals are predisposed, especially sheep and goats, though the An- 
gora sheep is apparently immune. In man the disease is contracted 
in certain occupations, as wool-sorting, tanning, etc., and by the inges- 
tion of the flesh or milk of an infected animal. The Bacillus anthracis 
is a rod-shaped micro-organism, from two to twenty-five microns in 
length, non-motile (thus distinguished from the similarly shaped but 
motile Bacillus subtilis), often united, and grows with great rapidity. 
Characteristic cultures may be made on gelatin plates at ordinary tem- 
peratures. The bacillus is easily killed, but the spores are very resist- 
ant. For seven successive years Ziegler was able to produce anthrax in 
mice by inoculations from similarly prepared pieces of dry catgut which 
contained the spores. Two sets of lesions are found, depending upon 
the method of invasion, — by skin or mucous membranes. I. External 
Anthrax. — (1) Malignant pustule. At the site of inoculation appears 
a papule which rapidly becomes a vesicle; later a brown eschar is 
formed, surrounded by small vesicles and an extensive area of brawny 
induration. The neighboring lymphatics are swollen, tender, and hard. 
(2) Malignant anthrax oedema. This is an extensive oedema affecting 
the eyelids, the head, arm, and often the entire upper extremity. It 
may terminate in gangrene, enteritis, peritonitis, or endocarditis. II. 
Internal Anthrax. — (1) Thorax. Very soon after death the upper 
extremities, both anteriorly and posteriorly, become dark purple, the 
nails are blackish blue, and dark chocolate-colored fluids issue from the 
mouth and nose. The cellular tissues of the upper part of the chest 
are emphysematous and crackle on pressure. On opening the thorax 
these tissues are often found infiltrated with blood and a gelatinous 
effusion. The pleurae contain much serum (two or three pints), the 
right more than the left. The pericardial fluid is also increased (six or 
eight ounces). The lungs are engorged with dark-colored blood. 
Some portions are cedematous, others harder than normal and of a 
darker-red color. The bronchial glands are swollen, hemorrhagic, and 
friable. The heart-muscle is dark colored, soft and flabby; the heart 
may be empty or contain dark, semifluid blood in all its cavities. The 
lining membranes of the heart and larger blood-vessels are stained a 



J()J POST MOU I 1--M i:\.\MlNATIONS 

color varying from cherry-red to dark chocolate, according to the time 
which has elapsed since death. The serous membranes throughout 
show extravasations oi blood. (2) Abdomen. The intestines show 

ns consisting of dark infiltrated spots (phlegmonous inflamma- 
tion ), about the si/e of a dime, with a greenish or grayish slough in the 
centre, which are composed mainly of anthrax bacilli situated chiefly 
in the lumen of the blood-vessels (Striurrpell). The cavity contains 
considerable serum or there may be gelatinous oedema; hemorrhages 
appear in the serous membrane. The liver shows less change than any 
other organ ; it may be normal. The spleen may be larger than natural 
or normal in size and appearance. (3) Kidneys. The parenchyma is 
gorged with dark blood, and hemorrhages appear in the capsule. (4) 
Brain and spinal cord. Extravasations of blood are discovered between 
the membranes and sometimes small infarcts are found. In a case 
which I had the opportunity of studying for Dr. T. G. Morton, the 
pustule was on the palm of the hand. The disease was probably 
contracted from a bone fertilizer while working with a trowel in the 

len. Early excision of the pustule, with the application of carbolic 
acid to the wound, was followed by recovery. (5) Retropharyngeal 
abscess may be of this origin. 

Beriberi. — An infectious disease of tropical and subtropical coun- 
tries, characterized by muscular pains and weakness, disseminated 
neuritis, cardiac failure, and general anasarca. Little regarding its 
origin is definitely known. Various micro-organisms have been sug- 
gested. Overcrow-ding and a fish diet may predispose. Two types, 
the cedematous and the paralytic, are recognized. The special lesion 
appears to be in the peripheral nerves. They are swollen and hemor- 
rhagic, but at times appear normal. The lesion is a parenchymatous 
neuritis. Atrophy of striated muscles may appear, in which case they 
are dry and shining, or the affected muscles, including the heart, are 
pale, flabby, .and fatty. Evidences of general anasarca, affecting the 
upper extremities most, are present. 

Cholera Asiatica. — An acute infectious disease originating in 

tern countries, characterized by the presence of spirochaeta and by 
a profound inflammation of the bowel. The comma bacillus of Koch 
motile, screw-shaped micro-organism about half the length of a 
tubercle bacillus, but thicker. The bacilli are found in large numbers 
in the rice-water stools, but rarely in the vomit. The position of 
the body is characteristic, the extremities being flexed, the fists 



MICRO-ORGANISMAL DISEASES 



293 



closed, and the abdomen scaphoid. There is cyanosis of the skin. 
( 1 ) In very acute cases the intestinal lesions are not characteristic, 
bnt the bowel contains large quantities of " rice-water." In more 
protracted cases the bowel presents a mapped appearance, — some 
areas hyperaemic and some anaemic, some hypertrophic and others 
ulcerated. The inflammation is well marked in the Peyer's patches. 
The serous membrane is sticky and of a rosy color. The blood-vessels 
are prominent and the body looks thin and shrunken. The mesenteric 
glands are swollen, soft, and of a reddish color. (2) The stools are 
largely serous and contain masses of columnar epithelial cells and 
almost pure cultures of the micro-organism. (3) The kidney is swol- 
len, of a violet hue, and shows the changes of acute diffuse nephritis. 
(4) The liver shows little alteration except cloudy swelling, with 
minute areas of focal necrosis. (5) The heart is flabby. Its right 
side is usually distended with tarry blood. The left heart is usually 
empty. (6) The lungs are collapsed and show marked congestion at 
their bases. Pneumonia and pleurisy may develop, and abscesses are 
not uncommon. (7) There is a decided tendency to the formation of 
diphtheritic exudate on mucous membranes, particularly in the throat. 
(8) The cceliac ganglion is hyperaemic or even hemorrhagic (Roki- 
tansky) . (9) All the abdominal organs are very dry. 

Dengue. — An acute infectious disease, prevalent in our Southern 
States, and generally known as " break-bone fever." It is bacterial in 
its origin; a therapeutic serum being now made like the antitoxin of 
diphtheria. The large and small joints become red and swollen. There 
is commonly a rash, but this has no distinctive character. General 
enlargement of the lymphatic glands is not uncommon. Being rarely 
fatal, no detailed observations have been made regarding the patho- 
logic anatomy of this disease. 

Diphtheria. — An acute infectious, contagious disease, charac- 
terized by the presence of the Klebs-Loffler bacillus and of a false mem- 
brane. This bacillus is a non-motile micro-organism which, when 
grown on blood-serum, assumes a great variety of shapes. It is easily 
cultivated on albuminous media in from twelve to sixteen hours. The 
bacillus is fairly resistant, and will live for months under favorable 
conditions. Many other organisms produce a similar membrane, and 
the identity of this organism with the pseudobacillus of diphtheria, 
the bacillus of scleroderma, and the organism of ozsena is believed by 
many, but the subject is still sub judice. The presence of the organism 



J()| POST-MORTEM EXAMINATIONS 

in well persons is a fact of great interest. The forms of the disease are 
nasal, pharyngeal, laryngeal, and cutaneous. The characteristic lesion 
of diphtheria is a false membrane, beginning early as a slightly raised, 
opaque, whitish-yellow spot on the mucous membrane. As a rule, it 
grows rapidly, becoming thicker, of a grayish or greenish hue, and 
firmly adherent to the underlying tissues. In the early stages if an 
attempt be made to remove it, there is left behind a raw bleeding sur- 
face. In the later stages the membrane becomes less firmly adherent, 
soft, shreddy, and somewhat easily detached. The diphtheritic patches 
may become hemorrhagic, the color being then dirty brown or grayish 
green. The blood not only infiltrates the submucous layer but also 
the pseudomembrane. When the submucous layer and the surround- 
ing connective tissue become markedly infiltrated, the inflammation is 
said to be phlegmonous. There is great swelling and pus soon forms. A 
retropharyngeal abscess may be of diphtheritic origin. In nasal diph- 
theria the membrane may be slight in extent or may entirely block up 
the nasopharynx. It is apt to lead to extension of inflammation to 
the membranes of the brain. In the pharyngeal form the exudate is 
usually first seen on the tonsils. It is apt to be very extensive and 
extend into the mouth, the oesophagus, and even the stomach. In the 
laryngeal form the amount of exudate is often very great: it may 
entirely occlude the air-passages and extend to the lungs and the 
bronchial tubes, even to those of the third and fourth dimensions, but 
as it extends it gets softer and thinner. In this form the pharynx may 
be entirely free from membrane. The cutaneous form is somewhat 
less common; it is apt to occur about wounds, the false membrane 
being seldom extensive. In nearly all cases of diphtheria there is 
marked inflammation of the neighboring lymphatic glands and often 
of the salivary glands. There is apt to be a bronchopneumonia. There 
are small atelectatic patches surrounded by areas of inflammation. 
Should the diphtheritic membrane become gangrenous, the process is 
liable to extend to the lung. Klebs-Lofner bacilli are usually not found, 
but cocci of various kinds are numerous. Endocarditis is extremely 
rare, but changes in the fibres of the heart-muscle are comparatively 
common. The serous membrane often shows ecchymoses. The kid- 
show more or less diffuse inflammation, which may be 
hemorrhagic, and albuminuria is a constant symptom of the disease. 
The other organs show the ordinary febrile changes. In malignant 
es the micro-organisms may be found in the bladder and the internal 



MICRO-ORGANISMAL DISEASES 295 

organs. As a rule they do not penetrate below the submucosa at the 
site of the lesion. Orth describes an enteritis nodularis in which the 
follicles and Peyer's patches are markedly swollen and hypersemic 
Growths may occur in various mucous membranes, as in the eye, the 
oesophagus, the vagina, in exstrophy of the bladder, etc. 

Erysipelas. — An acute contagious disease, characterized by a 
rash, and due to the Streptococcus or Diplococcus efysipelatis. The 
micro-organisms gain entrance through a wound or abrasion of the 
skin or mucous membrane. Three types of erysipelas are noted, — sim- 
plex, ambulans, and phlegmonosum. In uncomplicated forms little 
more than an inflamed oedema is seen. The micro-organisms may be 
found post mortem in the lymph-spaces and in the zone of spreading 
inflammation. In severe forms the face is enormously swollen, the 
eyes are closed, the lips cedematous, the ears thickened, and the scalp 
swollen. Blebs and vesicles often appear upon the eyelids, ears, and 
forehead. Small cutaneous abscesses about the cheeks, forehead, and 
neck are common, while beneath the scalp large quantities of pus may 
accumulate. There is enlargement of the cervical glands, but this is 
masked by the oedema. Erysipelas of the phlegmonous type may ex- 
tend to the intermuscular fascia. It is then likely to be gangrenous, 
particularly when following hemorrhagic contusions. This form, be- 
sides being the cause of acute purulent oedema, may result in emphy- 
sematous inflammation when gas-producing germs are associated. 
Infarcts often occur in the lungs, spleen, and kidneys ; these are usually 
septic in character. Endocarditis ulcerosa is particularly common. 
Albuminuria is a constant complication, but true nephritis is only occa- 
sionally seen. Septicaemia, septic pericarditis, and pleuritis are of com- 
paratively frequent occurrence. Acute atrophy of the liver sometimes 
occur-. 

Fever, Glandular. — An infectious disease of childhood, charac- 
terized by marked enlargement of the cervical glands. It is bacterial 
in origin and occurs between the ages of one and ten years. The dis- 
ease is rarely fatal. The cervical glands are swollen and softened ; 
the}- seldom suppurate, and the adjacent skin and mucous membrane 
show no marked changes. 

Foot-and-mouth Disease. — Stomatitis aphthosa epizootica is an 
acute contagious disease, occurring most frequently in cattle and sheep, 
but found also in persons who come in contact with the disease in ani- 
mals. It begins as a small vesicle (which is at first clear, later grayish) 



2 q6 POST MORTEM EXAMINATIONS 

on the lips, chocks, or pharyngeal mucous membrane. When the vesicle 
readies a diameter <>f from one and a half to three centimetres, it bursts, 
leaving a shallow ulcer, with oval, circular, or irregular edges. The 
affected mucous membranes arc inflamed, swollen, and cedematous, and 
there is considerable exudate. The lesions are also found on the udder 
and feet, usually appearing after the eruption in the mouth. The post- 
mortem appearances are most varied, consisting in oedema, hemor- 
rhagic infiltrations, fatty changes in the parenchymatous organs, etc. 
I. filler and Frosch consider the disease to be due to an organism so 
minute that it passes through the finest filters and is not visible with 
our present methods of staining. A colored illustration of the lesion 

vn in Kin's Atlas der Thierkrankheiten, 1896. 

Fra.mbcesia. — Yaws is a contagious disease of the skin, character- 
ized by an indefinite period of incubation and the presence of dirty 
or bright red-raspberry-like tubercles. It is presumably of microbic 
origin. The eruption begins as a papule, usually at the site of an old 
wound. In a few days the papules are scattered over the body; they 
rapidly enlarge and become tubercles, which are generally circular in 
shape, and vary in size from that of a pin's head to a small apple. The 
epidermis splits or cracks, exposing a raw granulating surface, which 
rarely ulcerates. The disease is by some supposed to be a modified 
form of syphilis. In his excellent work on Tropical Diseases, Man- 
son states that the question of their identity is certain to be debated 
until the respective germs of yaws and syphilis have been separated, 
cultivated, and inoculated, though he considers them to be specifically 
distinct diseases. 

Glanders. — A contagious disease occurring most frequently in 
horses and asses, the exciting cause being the Bacillus mallei. Two 
forms are recognized : (a) Glanders proper, (b) Farcy. (1) Glan- 
ders proper is an acute disease, essentially a necrotic alteration (Unna), 
occurring most frequently on the mucous membrane of the nose and 
upper respiratory tract. Its characteristic lesion is a node or tubercle, 
which is at first spherical, later becomes flattened, then breaks down 
and presents more or less extensive ulcerations which tend to run 

ether. The mucous membrane is swollen, is of a purplish or dark- 
red color, and there is considerable exudate from the ulcerating sur- 

s. The pr< cess may extend to the lungs, the most prominent lesion 
being a catarrhal pneumonia, in which the diseased areas show a 
marked tendency to break down, with the formation of abscesses. An 



MICRO-ORGANISMAL DISEASES 297 

eruption of papules, which soon become pustular, frequently appears 
upon the face and about the joints. The cervical glands are usually 
much enlarged. A dirty-yellow pasty mass of pus in the gastrocnemii 
is probably due to glanders. Chronic glanders usually occurs in the 
nose and is often mistaken for a chronic coryza. There are frequently 
ulcers about the turbinated bones. (2) Farcy may be acute or chronic. 
The acute form is of the nature of a phlegmonous inflammation at the 
point of inoculation. The process may be very extensive and lead to 
rapid suppuration of the surrounding parts. Metastasis to the sur- 
rounding tissues is common, accompanied by the formation of ab- 
scesses in the muscles. In chronic farcy localized tumors are found ; 
usually in the skin, the subcutaneous tissue, and the muscles. These 
tumors result in abscesses and may form deep ulcers. The disease in 
man has been described as a chronic specific pyaemia, characterized by 
eruptions on the skin and nasal mucous membranes, with frequent 
intramuscular abscesses. 

Goxorrhceal Infection. — Lesions due to the presence of the 
gonococcus. That organism has been found in the blood, which after 
death may be fluid or semiliquid and tarry-black in color. Manifesta- 
tions of the infection include: (1) Arthritis. — The inflammation is 
acute, periarticular, and extends along the sheaths of the tendons. It is 
a synovitis which rarely becomes purulent. (2) Conjunctivitis. — This 
occurs most frequently in the new-born. It leads to thickening and 
ulceration of the conjunctivae; erosions or entire destruction of the 
cornea may result. The skin of the lids may be destroyed. (3) Endo- 
carditis. — An acute form of simple or ulcerative endocarditis, from 
which pure cultures of the gonococcus have been made. (4) The results 
of gonorrhoeal infection are periurethral abscess, prostatitis, vaginitis, 
salpingitis, iritis, pericarditis, pleurisy, etc. All these lesions show a 
marked tendency to suppurative change. 

Hydrophobia. — Rabies is a convulsive disease due to the action of 
the toxins of the bacillus of hydrophobia on the higher nervous centres. 
The cerebrospinal system shows congestion of the blood-vessels. There 
are minute hemorrhages, most numerous in the medulla. The mucous 
membrane of the pharynx is congested and not infrequently covered 
with blood-stained mucus. This is true of the larynx, trachea, and 
larger bronchi, also of the lungs, oesophagus, and stomach. Experi- 
ments have shown abundant virus in the spinal cord, brain, and periph- 
eral nerves, but it has not been found in the liver, spleen, or kidneys. 



2 og POST-MORTEM EXAMINATIONS 

When a dog that is supposed to be mad has bitten a human being, the 
animal should not be at once killed, but permitted to live and kept 
under close observation until it shows unmistakable signs of rabies. 
It should then be killed and its body sent to a competent bacteriologist 
for microscopic study and inoculation experiments on rabbits. While 
the recent so-called rapid method of diagnosing rabies is not abso- 
lutely characteristic of the disease, it affords a most valuable and early 
means of tentative diagnosis, to be confirmed or disproved by subse- 
quent animal inoculation. The method employed is that of Babes, 
van Gehuchten, and Nelis, and is as follows: 1 Several intervertebral 
ganglia or a portion of the bulb are put at once into absolute alcohol, in 
which they are left for twenty-four hours. They are then transferred 

>ne hour to a mixture of absolute alcohol and chloroform, next put 
ne hour into pure chloroform, then for one hour into a mixture of 
chloroform and paraffin, and lastly for an hour* into pure paraffin. The 
sections are put in the oven for a few minutes, then passed through 
xylol, absolute alcohol, and ninety per cent, alcohol, after which they 
are stained for five minutes in methylene-blue, according to Nissl's for- 
mula, differentiated in ninety per cent, alcohol, dehydrated in absolute 
alcohol, and cleared in essence of cajuput and xylol. Other methods 
i »f preparing the tissues may be used, as the rapid fixation with ten 
per cent, formalin, subsequent freezing, and staining with hematoxylin 
and eosin. The microscopic changes are chromatolytic and capsular. 
The " "rabic tubercle" of Babes consists in the pericellular accumulations 
of the embryonal cells described by Kolesnikoff. The prolongations of 
the cells of the bulbar nuclei are shortened, the nuclei are altered or 
even obliterated, and the nerve-cells are invaded by the embryonal cells 
and small corpuscular elements. Atrophy, invasion, and destruction 
of the nerve-cells of the intervertebral and plexiform ganglia of the 
pneumogastric take place by cells newly formed from the capsule, 
which appear between the cell body and its endothelial capsule, in 
advanced cases the field even resembling an alveolar sarcoma. 

[nfluenza. — Hie grippe is an acute, epidemic, contagious disease, 
due to Pfeiffer's bacillus, and characterized by abrupt onset, great 
depression, and many sequelae. The bacillus is found in the nasal and 
bronchial secretions. It is one of the smallest organisms known, non- 

1 Ravenel and McCarthy, Proceedings of the Pathological Society of Phila- 
hia, 1 90 1, p. 93. 



MICRO-ORGAXISMAL DISEASES 



299 



motile, and stains well with Loffler's methylene-blue. On culture 
media it grows best in the presence of haemoglobin. (1) Lesions of 
the respiratory form are those of an acute inflammation of the mucous 
membrane of the upper respiratory tract and bronchial tubes. Lobular 
pneumonia is common, and is probably due to a mixed infection. 
Pleurisy is more rare, but may lead to empyema. Tuberculosis is apt to 
be exaggerated by an attack .of influenza. (2) In the gastro-intestinal 
form the inflammation extends to the mucous membrane of the stom- 
ach and the intestines. It is seldom of a severe type. The spleen is 
usually enlarged in this form. The recent large number of cases of 
appendicitis is attributed by some to the wide-spread prevalence of 
this disorder. (3) In the nervous form mild degrees of meningitis 
and encephalitis are not uncommon. Abscesses of the brain have 
occurred in severe acute cases. In some epidemics accumulations of 
pus in the nasopharynx are exceedingly common. Complications. — 
Acute diffuse nephritis is quite frequent. Endocarditis, pericarditis, 
and thrombosis have been reported. Occasionally purpura is seen and 
also catarrhal conjunctivitis and iritis. In an autopsy on a child dying 
from meningitis following the grippe Dr. Kneass isolated for me the 
influenza bacillus. 

Leprosy. — Leprosy is an infectious disease characterized by the 
formation of a node or nodule, and due to the leprosy bacillus. The 
Bacillus lepra? has many points of resemblance to the bacillus of tuber- 
culosis. It, however, stains more readily, is more easily decolorized, 
and is present in far greater numbers in the lesions which it causes. 
( 1 ) The tubercular form starts as a small red spot in the corium, which 
either disappears or gives rise to the formation of inflammatory nodules 
of a brownish-red color, somewhat soft in consistency, and resembling 
a strawberry. The primary lesion is found most frequently in the skin 
of the face and on the surfaces of the knees, the elbows, the hands, 
and the feet. It may also involve the conjunctiva and the mucous 
membrane (particularly the nasal), the cornea, and the larynx. This 
form of the disease is apt to be exceedingly chronic, the surrounding 
tissues showing marked fibroid changes. The tubercles at times 
undergo fatty disintegration and in this way become swollen. (2) In 
the anaesthetic form the leprous process gradually involves the periph- 
eral nerves, first causing a perineuritis, then obliterating them and 
producing marked trophic changes, consisting in necrosis and ulcera- 
tion with extensive loss of substance, as of fingers, toes, and even 



> (H) POST-MORTEM EXAMINATIONS 

limbs. There is greal loss of hair and the face often shows marked 
ravages of the disease. Death results not infrequently from laryngeal 
complication or aspiration pneumonia. That leprosy may be cured in 
the sense of the lesions not advancing is now an established fact. Van 
Ilmitum 1 claims to have cultivated successfully the Bacillus lepra, 
while several investigators have recently given promising reports of the 
cry i >f a curative serum. 

Malta Fever. — Mediterranean fever is a chronic disease, resem- 
bling in its clinical course typhoid fever and malaria, occurring most 
frequently in the Mediterranean region, and due to the Micrococcus 
melitensis. Tt is often followed by swellings of the joints, profuse 
diaphoresis, anaemia, orchitis, and neuralgia. Young and previously 
healthy adults who are unacclimated are most frequently attacked, and 
it is a serious disease in the British garrisons. The micrococcus is 
found in large numbers in the spleen. The visceral changes are those 
common to all infectious diseases with high temperature. The small 
intestine is usually anaemic except in the upper part, where it may be 
intensely congested. The mesenteric glands show little change. The 
spleen is much enlarged and dark in color; its pulp is soft and friable, 
and sections show an increase in the lymphoid elements. The average 
weight is eighteen ounces. The liver is congested and its surface on 
section is pigmented. The kidneys are usually congested and may be 
slightly hemorrhagic. The agglutinative reaction can be obtained 
with the micrococcus and the blood of a patient affected with Malta 
fever. It should be remembered that this disease occurs in our new 
ms, and that soldiers and sailors on their return home may 
bring the affection with them. 

Measles. — Morbilli or rubeola is a markedly contagious disease, 
attended with a skin eruption and catarrh of the mucous membranes, 
and due to a micro-organism the identity of which is not yet definitely 
settled. This affection, as well as scarlet fever and German measles, 
must be distinguished from Duke's fourth disease, a malady having 
characteristics in common with all three disorders. Lesage, Canon 
and Pielicke, Czajkowski, and others have described organisms as 
causes of the disease. The post-mortem appearances in measles are 
chiefly those of its complications and sequelae. The skin, especially 
about the face, may be swollen and slightly cedematous, and may show 



1 Journal of Pathology and Bacteriology, September, 1902, p. 260. 



MICRO-ORGANISMAL DISEASES 301 

the remains of the characteristic rash, especially in the hemorrhagic 
type. Desquamation, when present, is in the form of fine branny scales 
The gastrointestinal mucosa is usually hypersemic; Peyer's patches 
are frequently swollen, sometimes markedly so. The lungs invariably 
show evidence of bronchitis, and almost invariably lesions of broncho- 
pneumonia with areas of collapse; less frequently lobar pneumonia 
may be found. The bronchial glands are invariably swollen. Pleurisy 
is less common. In debilitated infants severe stomatitis, cancrum oris, 
or ulcerative vulvitis may develop. In the middle ear catarrhal inflam- 
mation, which may go on to abscess formation, is not uncommon. Of 
the sequelae tuberculosis is the most important ; it is either miliary or a 
caseous pneumonia. Severe forms of conjunctivitis and ulcer of the 
cornea are not uncommon. Nephritis is exceedingly rare. There is 
cloudy swelling of the organs. 

Mumps. — An acute, infectious, contagious disease, characterized 
by a marked cellular infiltration of the parotid glands, which do not 
tend to suppurate or to become fibroid, and frequently complicated 
with metastases to the ovaries and mammary glands in females, and 
the testicles in males, (a) Probably due to a coccus infection, (b) 
Childhood and adolescence. Very young infants and adults are seldom 
attacked. Uncomplicated mumps is rarely fatal. Of the complications 
meningitis, acute mania, endocarditis, gangrene, and optic atrophy are 
the most important. 

Plague. — An acute, infectious, contagious, epidemic disease, due 
to the Bacillus pestis, occurring usually in the far East, but at present 
(1904 J widely distributed over the earth's surface, and characterized 
by marked glandular enlargements which tend to suppuration and by 
a general septic condition. The bacillus was discovered by Kitasato 
and Yersin. It is a short rod with rounded ends, and is found in the 
blood, glands, and viscera. Hossack found no buboes in thirty per 
cent, of his cases in Calcutta in 1900. Varieties. — (a) Bubonic, (b) 
Pneumonic, (c) Septic, (d) Intestinal, (e) Meningeal. (/) Car- 
buncular. Lesions : ( 1 ) At the point of inoculation, which usually 
occurs on the lower extremities, there appears a small spot (plague- 
corpuscle j which soon becomes a vesicle and then a pustule. (2) Fol- 
lowing primary inoculation, the inguinal glands become swollen, suc- 
ceeded in order by the axillary, cervical, popliteal, and then any of the 
glands in the body may become affected. The diseased glands swell 
rapidly and are at first tense and firm to the touch, but soon undergo a 



» 02 POST-MORTEM EXAMINATIONS 

suppurative change, and in rare cases gangrene ensues. It may be 
stated that it is the periglandular tissue which becomes oedematous and 
undergi >es septic inflammation. (3) Carbuncles may develop in the skin 
of the legs, hips, and back. Subcutaneous hemorrhages are very com- 
mon and may also occur in the mucous membranes. (4) The central 
nervous system, especially the brain, is deeply congested. The brain 
substance may become softened and the blood-vessels, especially the 
veins, are engorged. (5) The lungs are deeply congested, especially 
posteriorly, and are at times the primary seat of the disease. (6) The 
pericardium contains an excess of blood-stained fluid. The right 
heart is dilated with black, imperfectly coagulated blood, and the whole 
venous system is engorged. The heart-muscle is pale and somewhat 
softened. (7) The stomach antl small intestine contain blood or blood- 
stained fluid. There may be ulceration, but Peyer's patches are not 
affected. The spleen is greatly enlarged in all cases. (8) The dorsum 
of the tongue is coated, but the edges, the tip, and often the median 
raphe remain pink and clean; sometimes, however, becoming red and 
dry (Hossack). The disease must be distinguished from puerperal 
fever, septicaemia, pyaemia, smallpox, influenza, cerebrospinal menin- 
gitis, diphtheria, erysipelas, measles, gonorrhoea, syphilis, mumps, ma- 
laria, scrofulous glands, Hodgkin's disease, etc. In the case of a 
Chinaman suspected of having the plague, the writer found almost 
complete occlusion of the prepuce, with a discharge containing the 
gonococcus, and in the suppurating bubo a fat diplo-bacillus which did 
not stain by Gram's method. 

Relapsing Fever. — An acute, epidemic, contagious disease, not 
found at the present time in America unless imported, occurring in the 
same class of persons as typhus fever, giving rise to a fever which lasts 
from five to seven days, followed by relapses, and due to the Spiro- 
chetes of Obermeier, which are found in the blood only during the 
paroxysms of fever. This very motile organism is only rarely to be 

»vered at the postmortem. No characteristic or constant lesions 
are found after death. The following are sometimes present. ( 1 ) If 
dea tli occurs during the paroxysm, the spleen is large and soft; the 
pulp is purple. The follicles are enlarged and often obliterated, though 
they may he gray or whitish yellow in color. Infarcts are not uncom- 
mon. (2) The heart is flabby, of a pale dirty-gray color, and very 
friable. (3) The liver is more enlarged in this than in any other 
infections fever. Its color is uniform gray-red. Fatty degeneration 



MICRO-ORGANISMAL DISEASES 303 

may be marked. (4) The kidneys may retain their normal weight. 
The renal parenchyma is soft and flabby ; the cortical substance is 
increased and shows cloudy swelling. Hemorrhagic spots or lines 
radiating to the pyramids are often observed. (5) The lungs may be 
the seat of pneumonic infiltration, bronchitis, or bronchiectasis. (6) 
Hyperplasia of the bone marrow has been found. Complications. — 
(a) Pneumonia is frequent, (b) Rupture of the spleen, (c) Nephri- 
tis and hematuria, (d) Ophthalmia in certain epidemics, (e) Abor- 
tion usually takes place. (Osier.) 

Rheumatic Fever. — (a) Follows exposure to cold and wet. (b) 
Usually regarded as a coccus infection, though a bacillus has also been 
described as the etiologic factor. ( 1 ) The affected joints are swollen, 
tense to the touch, and somewhat hyperaemic. The fluid in the joint is 
turbid, and contains albumin, leucocytes, and a few flakes of fibrin, but 
rarely pus. There may be slight erosion of the cartilages. (2) Endo- 
carditis occurs in about sixty per cent, of all cases. The verrucose 
variety is most common. The mitral valve is most frequently involved. 
(3) Pericarditis may occur, with or without endocarditis. It may be 
fibrinous, serofibrinous, or, in children, purulent. (4) Myocarditis 
occurs most frequently in association with endopericarditis. It leads 
to weakening and dilatation of the heart-muscle, and is the most com- 
mon cause of sudden death in rheumatic fever. (5) Pleurisy and 
pneumonia occur in about ten per cent, of all cases. (6) Rheumatic 
nodules, varying in size from a small shot to a large pea, are found 
on the fingers, hands, and wrists. They may also occur about the 
elbows, knees, spines of the vertebrae, and scapulae. (7) Meningitis 
is extremely rare. (8) Purpura may be present. 

Rheumatism, Chronic. — (1) The synovial membranes are in- 
jected. There is usually not much effusion. The capsules, ligaments, 
and sheaths of the tendons are thickened. There may be erosion of the 
cartilages. As a result of these changes, the joints are often deformed 
and ankylosis may occur. (2) Muscular atrophy, especially about the 
joints, frequently follows. (3) Valvular heart-lesions, due to sclerotic 
changes, are of common occurrence. 

Rubella (Rotheln, German Measles). — This disease is rarely 
fatal in uncomplicated cases. There is no distinctive lesion other than 
the rash, which may fade entirely after death. 

RLET Fever. — (a) The majority of cases occur before the tenth 
year, (b ) Infants and adults are usually exempt, (c) Cocci are fre- 



,Qj POST MORTEM EXAMINATIONS 

quently found in the throat-lesions and in the blood. Class, of Chi- 
cago, claims to have isolated a specific coccus, which has also been 
ribed by Baginsky. I i ) Rigor mortis is usually well marked. 
Decomposition may set in. early and develops with exceptional rapidity, 
cadaveric lividity usually appearing before death. (2) The blood is 
dark in color, thin, and coagulates imperfectly. The vessel-walls are 
usually stained. (3) Except in the hemorrhagic form the skin after 
shows a trace of the rash. (4) In the throat follicular 
tonsillitis, diphtheritic membrane, or suppuration may be present. 
Punctate hemorrhages, especially about the mouth, are always ob- 
served. (5) Catarrhal inflammation of the gastro-intestinal mucous 
membrane is not uncommon. The follicles of the small intestines are 
swollen, red. and may even be hemorrhagic. (6) In severe cases an 
intense lymphadenitis, with much inflammatory oedema, is found in 
the neck. This may lead to suppuration or even gangrene, and in rare 
es to ulceration of the carotid artery and fatal hemorrhage. (7) 
The kidney lesions are most important. Acute diffuse nephritis is 
present in a majority of cases. It is frequently of the glomerular 
type and may be hemorrhagic. This lesion is not infrequently fol- 
lowed by the changes observed in chronic parenchymatous nephritis. 

(8) Endocarditis, which may be either simple or malignant, is not 
infrequent. Pericarditis and myocardial changes are less common. 

(9) The spleen is often enlarged, and shows the changes which char- 
acterize acute splenic tumor. (10) Hemorrhages into the subserous 

les beneath the pericardium, endocardium, and pleura are quite 
frequent. There is more or less cloudy swelling of all the organs. 
Complications. — (a) The most important is nephritis. The urine is 
small in quantity, of a high specific gravity, cloudy, and of a dark 
blood-color. It contains large amounts of albumin, free blood, and 
epithelial cells, with hyaline and epithelial tube-casts. (Edema may 
be slight or marked; in a few cases oedema of the glottis has caused 
sudden death, (b) Heart complications are next in importance. There 
may be endocarditis, pericarditis, or myocarditis, (c) Catarrhal pneu- 
monia, more rarely croupous pneumonia or pleurisy, may occur, (d) 
Involvement of the middle ear may lead to thrombosis of the lateral 
sinus, meningitis, abscess of the brain, or necrosis en masse of the 
middle ear. < e ) Adenitis may result. The glands of the neck are those 
most frequently involved. There may be great destruction and loss of 

lie. I /") Arthritis of a rheumatic type or more closely resembling 



MICRO-ORGAXISMAL DISEASES 305 

the gonorrhoeal variety may be found. In the latter affection only one 
joint is involved and suppuration may supervene. The toxin seems to 
act especially on the epithelial cells. In one of my cases death occurred 
in convulsions twenty-four hours after the onset of vomiting and with- 
out the appearance of any rash. The diagnosis was confirmed by a 
sister being attacked with the disease later on. 

Scleroderma (Hide-bound Skin). — (1) Circumscribed Form. 
— On the skin are found patches varying in size and of a waxy or dead- 
white appearance. They are brawny, hard, and inelastic. (2) Dif- 
fuse Form. — This form usually occurs in the extremities or on the face. 
Gradually a diffuse brawny induration develops. The skin becomes 
firm, hard, and so closely united to the subcutaneous tissue that it can- 
not be picked up or pinched. The color may be natural. The skin is 
commonly glossy, drier than normal, and unusually smooth. 

Smallpox. — (a) Bad hygiene, (b) Improper vaccination, (c) 
Season, fall or winter, (d) Streptococci are found in the characteristic 
lesions. Councilman 1 has announced the discovery of a protozoon. 

( 1 ) The characteristic lesion of smallpox is a rash. On the skin may 
be seen papules, umbilicated vesicles, pustules, and crusts. A shot-like 
feel of the papules upon the forehead and wrist is quite characteristic. 

(2) The rash may also be found upon the mucous membranes from 
the mouth to the rectum, but on account of the moisture the pocks are 
not quite so characteristic in these situations as upon the skin. In some 
cases there is deep ulceration, especially in the larynx, which may be 
followed by necrosis of the cartilages. (3) Swelling of Peyer's patches 
is not uncommon. (4) In the hemorrhagic form of smallpox extrava- 
sations of blood are found on the serous and mucous surfaces, in the 
parenchyma of the organs, in the connective tissue, and about the 
nerve-sheaths. They have also been observed in the bone-marrow and 
in the muscles. (5) As a rule, the spleen is markedly enlarged, but it 
may be small, very dark, and firm. The liver shows evidences of 
parenchymatous inflammation. (6) The heart is flabby and pale. 
The myocardium shows cloudy swelling and fatty degeneration. It is 
often dark brown in color and may be firm to the touch. The cavities 
contain little or no clotted blood, and the arterial trunks are nearly 



'See Ziegler's General Pathology, translation by Cattell, 1895, p. 39: "It is 
not impossible that other infectious diseases — for instance, smallpox — are caused by 
parasites that belong among the protozoa." 



3 o6 



POST MOR l EM KXAMINATIONS 



empty. (7) Lesions of the kidney are not common. It may show 

cloudy swelling and areas of focal necrosis, or the pelvis may be 

blocked with dark clots which sometimes extend into the ureters. (8) 

ence of the scar resulting from vaccination is very often noted. 

The epidermis o\ the hands and feet may be shed entire. The 
skin is sometimes plum-colored. (10) The face may be swollen. In 
black smallpox there may he found hemorrhages in all the numerous 
membranes and in joints. The cornea may be sunken. Complications. — 

Bronchopneumonia is almost invariably present in fatal cases; 
lobar pneumonia and pleurisy less commonly, (b) Albuminuria is 
frequent, but true nephritis rare, (c) Purulent changes in the arteries, 
es, conjunctiva, and middle ear are common, (d) Ulcerative laryn- 
gitis with (edema sometimes causes death. (<?) Myocarditis, endocar- 
ditis, and pericarditis are comparatively common. At the postmortem 
the odor is so characteristic that the disease may be recognized by this 
means alone. The physician should always vaccinate himself both be- 

and after making an autopsy on a smallpox case. 
Sprue (Psilosis). — A chronic remittent inflammation of the 
whole or part of the mucous membrane of the alimentary canal, occur- 
ring principally in persons residing, or who have resided, in tropical 
or subtropical climates. Apparently nothing is known of its origin. 
At postmortem the thoracic organs, the abdominal viscera, and the 
tissues generally are found to be much wasted, giving the body a mum- 
mified appearance. The bowel is exceedingly thin, and on opening it 
a thick layer of dirty viscid gray, tenacious mucus is seen. On re- 
moving this, areas of congestion, ulceration, pigmentation, or thicken- 
ing may be found. The mesenteric glands are generally enlarged. 

Syphilis. — Lustgarten and van Niessen have described specific or- 
ganisms, neither of which has been definitely accepted. Classification. — 
I. Acquired Form. — (a) Primary, (b) Secondary, (c) Intermediate 
period, (d) Tertiary. II. Hereditary Form. — (a) Primary, (b) 

ndary. The following lesions should be looked for in making a 

mortem: (1) The initial lesion or its scar. (2) Lymphatic en- 
largement, especially of the groin, neck, and elbow\ (3) Various skin 

■is and thinness of the hair. (4) Mucous patches. (5) Onychia 

dactylitis. (6) Gumma in the viscera, skin, subcutaneous tissues, 
muscles, etc. (7) Parotitis. (8) The bones for periostitis or osteo- 
myelitis. (9) The eye for iritis or choroiditis. (10) The bowels for 
icially the rectum. (11) The nervous system for tabes, 



MICRO-ORGANISMAL DISEASES 307 

dementia paralytica, and other forms of sclerosis. I. The lesions found 
in the primary stage are: (1) The chancre. This begins as a small 
red papule, usually situated at the junction of the skin and mucous 
membrane. It gradually enlarges and breaks in the centre, leaving a 
small ulcer with indurated edges and base. (2) The neighboring lym- 
phatic glands are enlarged and hard. II. Secondary Stage. — (1) Cuta- 
neous eruptions of all forms. As a rule, the syphilide is polymorphous, 
varying in form from an erythema to a pustular eruption. It is sym- 
metrically distributed and of a reddish-brown or copper color. It 
appears most frequently on the chest, abdomen, and flexor surfaces of 
the arms. (2) The mucous patch is a softened and macerated epithe- 
lium, and appears on the mucous membrane or on the moist regions 
of the skin. It is most frequently found in the mouth, in the throat, 
and about the anus. The mucous patch is irregularly shaped, non- 
inflammatory, and does not discharge pus. (3) The hair of the scalp 
is decidedly thin. (4) Ulcers may be seen on the tonsils and larynx. 
(5) There may be warts about the vulva and anus. (6) Iritis is com- 
mon; retinitis rare. (7) The finger-nails may be diseased, forming 
dry or moist onychia. (8) Periostitis may be present. III. In the 
intermediate stage there are but few lesions: (1) Gumma of the tes- 
ticles and (2) choroiditis are the only ones found. IV. Tertiary 
Stage. — ( 1 ) The late syphilides show a tendency to ulcerate and 
destroy the deeper layers of the skin, leaving scars. Rupia may de- 
velop. (2) The gummata are the characteristic lesions, and may be 
hard or soft. The former develop in the internal organs and in the 
mucous membranes. They most frequently terminate in cicatrization, 
forming stellate scars which often cause marked deformities. Soft 
gummata are found in bones, skin, etc. They tend to break down and 
ulcerate, leaving chronic indolent, often serpiginous, sores. (3) When 
there has been prolonged suppuration, amyloid degeneration of the 
liver, spleen, and kidneys often occurs. This is especially true with 
regard to rectal syphilis in women. (4) Circulatory System. — The 
heart frequently shows sclerotic changes of the valves, especially about 
the aorta. (5) The blood-vessels present arteriosclerosis or atheroma- 
tous changes. (6) In the central nervous system scleroses of the 
brain and cord and gummata are common. V. Congenital Syphilis. — 
(1) At birth the infant is usually apparently healthy, but it may 
present well-marked lesions. (2) There is wasting, and pemphigus 
is noticed on the hands and feet. (3) The lips may be ulcerated and 



POST MORTEM EXAMINATIONS 

the mouth and anus fissured. (4) There is inflammation of the nasal 
mucous membrane; hyperaemia with papillary infiltration is present 
and necrosis of the bone may occur. (5) The spleen and liver are 
enlarged. (6) The lungs maj present the lesions of white pneumonia 
or miliary gummata. (7) The long bones usually show characteristic 
changes, and the epiphyses may be separated. (8) Later the child 
looks prematurely old. The teeth are wedge-shaped and the cutting 
edges notched ( 1 lutchinsoirs teeth). (9) Eye lesions may be seen, as 
interstitial keratitis. (10) Dactylitis is not uncommon. 

Syphilis of the Brain and Cord. — (1) Gummata are usually mul- 
tiple, varying in size from a pea to a walnut. In the cerebrum they 
occur along the sulci. Heubner describes two forms. In the first 
variety they are grayish or grayish red in color, soft, and not sharply 
defined. On section they are moist and exude a small amount of juice. 
In the second form they are quite hard and dry. Their outline is dis- 
tinct. On section they may be cheesy and look not unlike tuberculous 
growths. An enarteritis around them exists and causes softening. 
(2) Gummatous arteritis and sclerosis of both arteries and nerve tissue 
may exist. (3) There may be softening due to obstruction of the 
blood-vessels. Several years ago a man was condemned to death 
tor killing a person in cold blood. A commission of experts pro- 
nounced him sane. The man committed suicide by hanging, and I 
found at the postmortem numerous gummata of the brain, situated 
especially in the right temporal and frontal regions. 

Syphilis of the Circulatory System. — (1) Gummata are rare. (2) 
Fibrosis of the heart-muscle is common. (3) Sclerosis of the valve is 
frequent. (4) Arteriosclerosis, aneurism, and endarteritis obliterans 
are common. 

Syphilis of the G astro -Intestinal Tract. — (1) The oesophagus is 
rarely affected. Ulceration or stenosis may be present. (2) Ulcers, 
phlegmonous inflammations, or abscesses may be found in the pharynx. 
Ulcers may occur in the small intestine and caecum. (4) The rec- 
tum is not infrequently the seat of cicatricial contraction. This lesion 
is most often to be seen in women. The lesions that syphilis produces 
in the ^astro-intestinal tract are (a) chancre, (b) ulcers, (c) localized 
fibrous patches, (d) gummata, (<?) miliary nodules, (/) condyloma- 
Syphilis of the Kidneys. — (1) Gummata are not infrequent. (2) 
Acute syphilitic nephritis may occur. (3) Chronic interstitial nephri- 



MICRO-ORGAXISMAL DISEASES 309 

tis is more common. This is a localized nephritis caused by the result- 
ant shrinking- and marked irregularity of the surface of the kidney. 
It is sometimes hard to distinguish it from old infarcts, but the change 
in color, which in syphilis is gray and in infarcts is brown, is a rather 
good point of differentiation. 

Syphilis of the Larynx. — (a) Congenital, (b) Acquired, which 
may be secondary or tertiary. ( 1 ) In the secondary form there is 
erythema, with symmetrical, superficial, whitish ulcers on the cords or 
ventricular bands. (2) Mucous patches are occasionally seen. (3) In 
the tertiary form true gummata may appear towards the base of the 
epiglottis. These break down, producing deep flask-shaped ulcera- 
tions, which may heal by connective tissue that shrinks and produces 
stenosis. (4) Islands of connective tissue commonly appear between 
the cicatrices and form inflammatory excrescences. (5) The neigh- 
boring cartilages may show necrotic changes. (6) A fatal termination 
may result from perforation of an artery. 

Syphilis of the Liver. — (1) In diffuse syphilitic hepatitis there is 
marked fibrous change. The organ is hard, firm, and resistant. The 
disease usually begins with a perihepatitis, which frequently causes 
adhesions to the surrounding structures. With contraction of the 
fibrous tissue great deformities of the liver become manifest. Capillary 
bile-ducts may be present in abundance in the cirrhosed portion. (2) 
The smaller gummata are pale-grayish nodules, the larger ones pale 
yellowish in color. Usually they are multiple (miliary). Although 
they may be present in any part of the organ, the most common situa- 
tion is at the junction of the right and left lobes. Great deformity 
results from healing and contraction. 

Syphilis of the Lung. — (1) In white pneumonia of the fcetus the 
affected lung is heavy and airless. On section it presents a grayish- 
white appearance (white hepatization). (2) Hereditary gummata 
are small in size, grayish in color, firm in consistence, and more or less 
symmetrically distributed throughout the lung. (3) Acquired gum- 
mata vary in size from a pea to a goose's egg. They are grayish yellow 
in color and are embedded in connective tissue. The parts around them 
are hard and brawny and of a glossy lustre. These gummata may 
break down and form cavities. This condition is called syphilitic 
phthisis. (4) There may be a fibrous interstitial pneumonia in which 
the lesions are hard, large, and pale or dark grayish red in color. The 
middle of the right lung or either apex is the part most frequently 



, I0 POST-MORTEM EXAMINATIONS 

involved. (5) The pleura is thickened. (6) Endocarditis may extend 
to the hepatic artery and portal vein. 

Syphilis of the Testes. — (1) Gummatous growths usually involve 
the epididymis, which becomes a hard mass, from the size of a bean to 
that of a walnut It affects the head more commonly than the body of 
the epididymis. (2) In interstitial orchitis the progress of the disease 
■w . I lie organ is larger than normal and distinctly harder to the 
touch. The overlying skin is not adherent and there is no tendency to 
suppuration. 

Tetanus. — The bacillus of tetanus is a slender rod usually grow- 
ing in long threads. It is motile, grows on ordinary media at ordinary 
temperatures, and is anaerobic. It stains readily, but does not retain 
the stain very well. ( 1 ) The bacilli develop at the site of the wound, 
which is usually of a penetrating character, and do not invade the blood 
1 >r organs, except very rarely late in the course of the disease. (2) No 
characteristic lesions have been found. (3) The condition of the 
wound depends upon the kind and extent of the injury. (4) The 
central nervous system shows congestion, with perivascular exudations 
and granular change in the nerve-cells. Some investigators have found 
swelling and areas of disintegration in the gray matter of the cord, 
with exudation of a finely granular material and disintegrated blood. 
(5) In tetanus neonatorum the umbilicus may be inflamed. (6) The 
rectus muscle has been found ruptured as the result of a spasm. (7) 
Death may occur from heart-failure or asphyxia. 

Thrush. — This disease is due to the O'idium albicans, or thrush 
fungus. Parts affected: (1) The mouth, tongue, cheeks, etc., are 
more or less densely covered with minute, slightly raised, white spots, 
which are quite firm and adherent to the mucous membrane. When 
scraped off and examined microscopically, the characteristic fungus is 
seen. (2) Occasionally the fungus invades the oesophagus and grows 
to such an extent as seriously to obstruct its lumen. 

Tuberculosis. — Any morbid lesion produced by or through the 
agency of the tubercle bacillus, which is a rod-shaped micro-organism, 
measuring in length about one-half the diameter of a red corpuscle 
and in width two-tenths of a micron. It is bent upon itself, grows 
1 m agar containing glycerin, stains with difficulty, but retains the 
tenaciously. The best method of staining is by carbol-fuchsin 
and Gabbett's solution. When stained it often has a beaded appear- 
ance. It is morphologically similar to the bacillus of leprosy and the 



MICRO-ORGAXISMAL DISEASES 



311 



smegma bacillus. Tuberculous lesions are: I. Acute. — (a) Miliary 
tuberculosis, (b) Caseous pneumonia or phthisis florida. (c) Tuber- 
culous ulcerations. II. Chronic. — (a) Diffuse tuberculosis, ulcerative 
phthisis, or caseous tuberculosis. (b) Fibroid phthisis. (c) Cold 
abscesses. III. Modes of Invasion. — (a) Aerogenous. \b) Lympho- 
genous, (c) Hematogenous. IV. Characteristic Lesions of Tubercu- 
losis. — (a) Miliary tubercle, (b) Caseation, (c) Cold abscesses. 
(d) Ulceration. Characteristics of Tuberculous Lesions. — (1) Miliary 
tubercle is a small nodule about the size of a mustard-seed, grayish 
white in color, semi-translucent, raised above the surface, and primarily 
adherent to the surrounding structures. (2) In caseation or diffuse 
tuberculosis two or more miliary tubercles agglutinate, isolating the 
intervening healthy tissue and cutting off its blood-supply. The 
necrosed area loses symmetry of shape and arrangement and undergoes 
fatty degeneration. The area is yellowish in color, soft or firm in con- 
sistence, and is surrounded by an inflammatory zone. There is an 
almost complete absence of blood-vessels. (3) Cold abscess is most 
frequently found in association with tuberculosis of the vertebrae. It 
is frequently seen as a " psoas" abscess. The capsule of this abscess 
is more or less imperfect. It does not present the ordinary charac- 
teristics of a pyogenic membrane, the limiting wall being composed 
mainly of broken-down tuberculous tissue with more or less perfectly 
formed tubercles. The contents of the abscess are pale and of a some- 
what watery consistence, composed mainly of broken-down cells, fatty 
debris, and water. Bacteriologically the contents of the abscess are 
usually sterile. V. Distribution of Tubercles in the Body. — (a) The 
lungs are most commonly affected. In two hundred and seventy-five 
cases out of a thousand autopsies, the lungs were, with two or three 
exceptions, involved in all. Other organs were affected as follows: 
(b) Intestines in sixty-five cases, (c) peritoneum in thirty-six, (d) 
kidneys in thirty-two, (<?) brain in thirty-one, (/) spleen in twenty- 
three, (g) generative organs in twenty, (h) liver in twelve, (i) peri- 
cardium in seven, and (/) heart in four. (Osier.) VI. Fate of Tuber- 
culous Lesions. — Tuberculous lesions may terminate: (a) In resolu- 
tion, which is rare, (b) In fibroid changes. This sometimes occurs 
in the small intestine and may cause stenosis, (c) In caseation or sup- 
puration, (d) In calcification. ( 1 ) Resolution sometimes takes place 
when the area of tuberculosis is small, the blood-supply good, and the 
patient under favorable conditions, especially when leading an out-door 



» I2 POST-MORTEM EXAMINATIONS 

ei ce. | 2) In healing by fibroid change the area affected is first 
encapsulated and then by gradual pressure and absorption the affected 
area is removed, leaving a scar. (3) Caseation is by far the most 
common result of all tuberculous lesions. The process has been already 
described. Suppuration in tuberculous lesions is the result of the intro- 
duction of pyogenic organisms. (4) Calcification is the most fortunate 
ending of the tuberculous process, and it is estimated by careful ob- 
servers that seventy-five per cent, of all persons who die after the age 
of forty years show this form of tuberculosis in their lungs or pul- 
monary glands. 

Tuberculosis of the Alimentary Tract. — This form may be: (a) 
Primary in the mucous membranes, (b) Secondary to disease of the 
lungs or eating infected food, (c) It occurs rarely through extension 
from the peritoneum. I. Mouth. — (1) Primary tuberculosis, which 
is usually miliary. The tonsils are affected primarily more often than 
was formerly supposed. (2) Secondary to tuberculosis of the face, 
larynx, or lung. It may attack the tongue or cheeks and be miliary 
or caseous. II. Qisophagns. — (1) Primary tuberculosis is very rare. 
(2) Secondary tuberculosis through extension from the lungs or larynx 
is comparatively common. (3) The lesions may be miliary, caseous, or 
ulcerative. III. Stomach. — Tuberculosis of the stomach is compara- 
tively rare; Orth never saw a case. IV. Intestines. — The lesions occur 
in the ileum, caecum, colon, and rectum. The most frequent seat is 
in the ileum, just above the ileocecal valve, as it is here that stasis of 
the intestinal contents occurs and a favorable opportunity is given for 
the growth of the tubercle bacillus. (1) The large bowel is less fre- 
quently involved than the small bowel. (2) Small, firm, gray nodules 
develop, which soon soften and become yellow in the centre. If cut 
into at this stage, pus does not exude as in an ordinary abscess, but a 
thick caseous material may be pressed out. The mucous membrane 
over these nodules finally breaks down and the cheesy material is 
erupted. There remains an ulcer with swollen cheesy base and edges 
(primary tuberculous ulcer of Rokitansky), which soon combines with 
others and enlarges irregularly (secondary tuberculous ulcer of Roki- 
tansky). Miliary tubercles in the form of small gray nodules now 
appear at the base and edges of the ulcer and its immediate vicinity. 
Through the caseation of these, the ulcer enlarges both downward 
and laterally. The round ulcer becomes a long one, with its longer 
axis usually at right angles to the long axis of the intestine; it may 



MICRO-ORGAXISMAL DISEASES 313 

extend around the bowel. Hemorrhages may occur, particularly at 
the edges. The submucosa and muscularis are usually involved, and 
colonies of young tubercles may be scattered over the serous mem- 
brane. Perforation is rare. Gangrene may occur in a very rapidly 
developing ulcer. Healing sometimes takes place. (3) There may 
be solitary or multiple areas of cicatricial tissue. (4) Fistula in ano 
is quite common. V. ( 1 ) The liver is constantly involved in general 
tuberculosis. It is pale in color, often fatty, and presenting miliary 
tubercles or caseous masses which maj r break down into numerous 
small abscesses, especially about the bile-ducts. (2) There may be an 
increase in the connective tissues, leading to tuberculous cirrhosis. 

Tuberculosis of the Brain and Cord. — (a) Acute miliary infection. 
(b) Chronic meningo-encephalitis. (c) Solitary tubercles. I. Acute 
Miliary Tuberculosis. — (1) This is usually secondary to tuberculosis 
of the lungs, bronchial glands, or bones. (2) Miliary tubercles occur 
most frequently in the pia and arachnoid of the cerebellum, next in 
the cerebrum, then in the pons. They follow the direction of the blood- 
vessels. They are apt to lead to obliteration of the vessels and thus 
cause softening and necrotic changes. Serous, seropurulent, or sero- 
fibrinous exudate is also present. (3) This acute process may result 
in acute inflammation of the meninges, principally the pia and arach- 
noid. It is spoken of usually as acute hydrocephalus. This is most 
pronounced towards the base of the brain and occurs most frequently 
in children. I have found tubercle bacilli in fluid removed by Quincke's 
lumbar puncture. II. Chronic Meningo-Encephalitis. — The mem- 
branes at the base of the brain are most often involved, next in fre- 
quency the optic chiasm, the Sylvian fissure, and the interpeduncular 
space. The membranes are thickened, firmly adherent, and covered 
with a fibrinous, purulent exudate. The convolutions are flattened 
and the sulci obliterated. The cerebral substance is more or less 
cedematous. The lateral ventricles are dilated and contain a turbid 
fluid. III. Tuberculous Tumors of the Brain. — (1) Solitary tubercles 
are found most usually about the cerebellum. As a rule, they are 
attached to the meninges, often to the pia mater. (2) Cerebral soften- 
ing from pressure is not uncommon. The tubercles vary in size from 
a pea to a small orange. They are grayish yellow in color, caseous, and 
usually firm and hard, but the centre may be semi-fluid. They may 
be surrounded by submiliary tubercles, but are, as a rule, surrounded 
by a soft translucent tissue. (3) They may calcify. 



. I i POST-MORTEM EXAMINATIONS 

Tuberculosis of the Circulatory System. — (i) Primary tubercu- 
losis of the larger vessels is unknown; secondary lesions are not infre- 
quently found if carefully searched for. (2) In the lungs, brain, and 
other organs the smaller arteries are usually involved in acute infiltra- 
tion which leads to thrombosis. (3) Tubercles may develop in the 
walls of the vessels, particularly the muscularis, and undergo softening, 
which may result in hemorrhage or a wide-spread distribution of the 
tuberculous infection. 

Tuberculosis of the Genito-Uriuary System. — (a) Most common 
in males, (b) Age from twenty to forty years. I. The Kidneys. — 
1 1 ) These organs are frequently the seat of an acute miliary infection, 
which may be primary or secondary. The disease is most marked in 
the cortex. It may be limited to the areas supplied by a single blood- 
vessel. Necrosis and caseation rapidly follow. The miliary tuber- 
cles may be seen in a row in the direction of the vasa interlobularia. 
One or both organs may be affected, but at autopsy both are found to 
he enlarged. (2) Not infrequently one kidney may be completely 
destroyed and converted into a series of cysts; these contain a cheesy 
substance, and lime salts may be deposited in their walls. This is a 
chronic form of the disease and frequently starts at the apices of the 
pyramids. (3) The walls of the pelvis may be thickened and cheesy, and 
the mucous membrane converted into a necrotic ulcerating mass. The 
ureters are usually thickened, caseous, or ulcerated. II. The Blad- 
der. — Tuberculosis here is most common in men. ( 1 ) Infection of this 
organ is nearly always secondary to infection elsewhere, particularly 
in the pelvis of the kidney. The bladder is small, shrunken, thick- 
ened, and surrounded by sclerosed tissue. Ulcer formation is most 
common. It is lenticular in shape and is surrounded with red mucous 
membrane. Its seat of predilection is the trigone and fundus. Minute 
gray tubercles may be seen. In advanced cases ulcers are found. (2) 
To find tubercle bacilli in the urine centrifugation should be employed, 
and the precipitate stained in the usual manner for showing these 
nisms. Care must be taken not to get the smegma bacillus; it is, 
therefore, advisable that the urine be collected with the strictest pre- 
cautions. III. The Testes. — Infection may occur before the second 
It may be secondary to peritoneal tuberculosis. At times the 

iter part of the testis is destroyed, its stroma being replaced by a 

ened or still firm caseous deposit, which may be softened in the 
centre. IV. Tuberculosis of the ureters is very rare. V. Salpingitis. — 



MICRO-ORGANISMAL DISEASES 



315 



The oviducts are enlarged, the walls thickened and infiltrated, and the 
contents cheesy. It is usually bilateral. 

Tuberculosis of the Larynx. — The lesions may be primary or sec- 
ondary, usually the latter. The lesions found are : ( 1 ) Miliary tuber- 
culosis. (2) Diffuse tuberculosis. (3) Ulceration. In early cases 
the epithelium is intact, the tubercle starting in the mucosa or sub- 
mucosa. 

Tuberculosis of the Lung. — I. Acute. — (a) Miliary tuberculosis. 
(b) Phthisis florida, showing itself as bronchopneumonic tubercles, 
as lobar-pneumonic tubercles, or as a combination of both. II. 
Chronic. — (a) Ulcerative phthisis, (b) Fibroid phthisis. I. Acute. — 

( 1 ) In acute miliary tuberculosis the lesions are usually present in both 
lungs. They are frequently so small and transparent that they may be 
overlooked on macroscopic examination. At other times they are 
aggregated in localized spots or even become diffuse. In the latter case 
the lung is increased in size, is firm in consistence, in color is a darker 
shade of red, is heavier, and crepitates. The pulmonary vessels should 
be opened with the scissors, and seldom in the pulmonary arteries but 
often in the veins miliary tubercles can be seen, the infection having 
been brought through the circulation. Such tubercles may, however, 
be localized near an old caseous mass, the lymphatic system then 
being the transmitter. Local spots of emphysema are seen if the 
condition is not very acute. The tubercles may be peribronchial, peri- 
vascular, or in the parenchyma. There is a chronic miliary tubercu- 
losis which presents a combination of lesions of both acute miliary 
tuberculosis and phthisis and is the connecting link between the two. 

(2) Phthisis florida, or acute phthisis with formation of cavities, pre- 
sents a varied appearance. One lobe only, or more or less of the 
whole lung, may be affected. The organ is heavy; the implicated 
portions do not collapse and are firm and airless. The pleura is 
covered with a thin exudate. On section the condition may resemble 
red or gray hepatization or an intermediate stage between them. In 
other instances the lung presents a mottled appearance, some areas 
being intensely congested, others exhibiting a characteristic pale-gray 
gelatinous exudate, others caseous degeneration and not infrequently 
cavity formation. Recently affected areas of pulmonary tissue with 
croupous pneumonia are often seen. II. Chronic. — (1) In ulcerative 
tuberculosis apical involvement in relation to implication at the base 
exists in the proportion of five hundred to one, according to Kidd. 



,,,, POST-MORTEM EXAMINATIONS 

rhere are varied lesions. First, there are caseous nodules, which are 
grayish, white or yellow in color. Second, cavities may exist, which, 
if the ctsc is acute, have walls made up of soft caseous masses. In 
the more chronic cases these walls are replaced by pyogenic membranes 
of greater or less density, at times covered with granulations. Fre- 
quently trabecular arc seen in the walls; these are the blood-vessels, 
branches <)i the lung artery, which have resisted the tuberculous pro- 
The arteries sometimes become aneurismal. Their rupture may 
illowed by hemorrhage severe enough to cause death. Frequently 
they are contracted and empty, due to a previous endarteritis or throm- 
Third, pneumonic areas and evidences of chronic bronchitis are 
Fourth, ^»me thickening of the pleura is constant. This may 
be merely an acutely inflamed area rubbing against a corresponding 
area on the parietal pleura or it may be tightly adherent to it. Not 
infrequently perforation causes a pyopneumothorax. Fifth, enlarged 
bronchial glands are discovered which are caseous and often pig- 
mented. Lastly, the bronchi are thickened and the lumina of the 
smaller ones frequently obliterated. The larger tubes show caseous 
deposits in the submucous and fibrous coats. (2) In fibroid phthisis 
the organ is permeated with interstitial overgrowth. In some cases 
the interstitial change is most prominent; in others the tuberculous 
process is slightly more marked. The unaffected portions of the lung 
largely emphysematous and pigmentation is considerable. The 
righl ventricle and sometimes the whole heart are hypertrophied to a 
'enable degree. 
Tuberculosis of the Lymphatic Glands. — (1) Location, most fre- 
quent in the cervical chain. (2) Extension opposite that of the lym- 
phatic stream. (Treves.) I. Chronic Form. — (1) Hard. (2) 
Non-adherent. (3) Yellowish white in color. (4) Little tendency 
t<> break down and suppurate. (5) Tendency to be localized. (6) 
ergrowth of connective tissue considerable. In tabes Virchow 
compared them to a sectioned potato. II. Less Chronic Form. — (1) 
Not as dense. (2) Tendency to become adherent. (3) Gray or 
grayish white in color. (4) Tendency to liquefy and suppurate. 
ective tissue less in amount. (6) Tubercle bacilli more abun- 
dant. When tuberculous lymphatic glands are associated with phthisis, 
times found to have opened into a bronchus and caused 
the 1 This is particularly common in children, and especially 

when the middle and lower lobes are involved. 



M K RO-ORGANISMAL DISEASES 317 

Tuberculosis of the Mammary Gland. — (a) Female sex. (/;) 
Strumous temperament, (c) Age from the fortieth to the sixtieth 
year. The seat of predilection is the gland duct, (r) Induration is 
at first small and very slowly increases in size. (2) The nipple may 
be retracted. (3) The skin over the gland becomes riddled with 
sinuses with indurated edges. (4) Associated with lymphatic en- 
largement, tuberculosis o\ hone, or other tubercular involvement near 
the gland. 

Tuberculosis of the Peritoneum. — I. Miliary Form. — -( 1 ) On 
opening the abdominal cavity the serous membranes seem to he o>\ 
ered to a greater or less extent with miliary tubercles, which are 
present in the mesentery and the omentum also. Frequently the gray 
nodules follow the distribution of the blood-vessels. (2) In many 
cases there is little or no inflammatory exudate, although petechial 
hemorrhages are common. (3) The peritoneum, however, has not 
its normal shining surface, but is usually pale, somewhat sticky, and 
lustreless. (4) In many cases there is an effusion of straw colored 
or bloody fluid which may amount to a litre or more. Jt contains a 
considerable amount of albumin and some cells. 'The exudate is rarely 
purulent. II. Chronic Diffuse Form. — (1) The abdominal viscera 
and peritoneum are bound together by tough, firm, membranous bands 
of organized exudate and the peritoneal cavity is obliterated. (2) 
The intestinal coils are shortened and contracted, while the mesenteries 
and omentum are enormously thickened. (3) The capsules of the 
liver and spleen undergo extreme thickening, varying from a few 
millimetres to several centimetres. The organs are rough and irreg- 
ular in outline. III. Ulcerative Form. — (1) There is a formation of 
caseous masses that vary in size from a pea to a marble, and which 
tend to run together and break down, forming more or less extensive 
ulcerating surfaces. (2) Adhesions are formed of a serofibrinous or 
seropurulent character. (3) The new tissues are apt to become pig- 
mented and of or almost black color. (4) The intestinal walls 
are very friable. (5) Fistnke, opening at various points, arc nol 
infrequent. 

'Tuberculosis of Serous Membranes. — There are three groups of 
cases: (1) Acute miliary tuberculosis, which may develop very rap- 
idly and is accompanied by more or less serous but turbid exudate. 
(2) A chronic form characterized by exudation, the formation of 
chee- . and a tendency to suppuration. (3 In which 



• jg POST-MORTEM EXAMINATIONS 

the tubercles are hard and fibroid, the membranes much thickened, but 
with little or no fluid exudate. In these cases there may be no visceral 
tubercles. 

Tuberculosis of the Skin. — Anatomical warts are small papillary 
outgrowths frequently seen on the hands of those who make many 
autopsies. The process is chronic, and, as in the case of one of my 
helpers in the post-mortem room at Blockley, may give rise to general 
tuberculosis. The bacilli are few, and are best demonstrated by inocu- 
lation of some of the secretion into a guinea-pig. "the animal lives for 
a longer period of time than is usual when it is inoculated with tuber- 
culous material taken from other sources. Lupus vulgaris is a cuta- 
neous form of tuberculosis, characterized by the formation of nodules, 
which tend to break down, producing more or less ulceration. The 
tubercle bacillus is found in very few numbers. ( i ) The lesion begins 
as a small nodule, reddish brown in color and of soft consistence. 
These nodules vary in size from a pin-head to a cherry and quickly 
break down and ulcerate. The ulcers are more or less rounded and 
have a red base covered with granulations. The intervening tissues 
show diffuse infiltration and fibrous hyperplasia. Warty excrescences 
may develop in the epidermis or in the floor of the ulcers. The face 
is the most common seat of the disease. (2) In lupus of the larynx the 
lesion is surrounded by hypersemic, cedematous tissue. In the course 
of time smooth, hard nodules appear, causing great deformity of the 
parts. Softening and ulceration give the larynx a worm-eaten appear- 
ance. The disease follows the lymphatic channels. 

Typhoid Fever. — The intestinal lesions are : First week, intense 
catarrhal inflammation of the mucous membrane of the intestines 
and in the first few days only moderate swelling of the follicles. 
Towards the end of this week, however, there is more decided 
medullary swelling. Second week, the medullary swelling goes on to 
resolution or formation of eschar or, third week, ulcer formation. In 
the fourth week there is beginning cicatrization. The lesions are most 
marked in the lower ileum, but they also exist in the caecum and large 
intestines, rarely in the jejunum. Flyperplasia of the mesenteric lym- 
phatic glands and the spleen develops early in the disease. Cloudy 
swelling and fatty degeneration of the heart, liver, and kidneys may 
he present. Waxy degeneration and bleeding in the voluntary muscles 
should he looked for. Other lesions are lymphoma of the liver, acute 
nephritis, bleeding of the skin, hypostatic or catarrhal pneumonia, 



PARASITIC DISEASES 



319 



purulent bronchitis, perforation, and peritonitis. The Widal test and 
the diazzo-reaction may be determined post mortem. Paratyphoid or 
paracolon infections are more common than was formerly supposed, 
and furnish most interesting cases for thorough study. 

Yellow Fever. — The chief lesions are : ( 1 ) Bleeding from the 
mucous membranes. (2) Tarry blood. (3) High-grade fatty degen- 
eration of the liver. (4) Acute hemorrhagic inflammation of the 
stomach and intestinal mucous membrane. (5) Icterus. The inter- 
esting work done by Reed, Carroll, and Agramonte in Havana, in 
showing that this disease is dependent on the Stegomyia, a variety of 
mosquito, is one of the most important contributions to medical litera- 
ture of the past decade. The Bacillus X of Sternberg and the Bacillus 
ictcroidcs of Sanarelli are by some supposed to be identical, by others 
not to be the cause of yellow fever. There is an interesting illustrated 
article on this subject in the New Orleans Medical and Surgical Jour- 
nal for January, 1902. 

PARASITES. 
Pediculi. — (a) Pediculus capitis. — The female louse measures 
from one and eight-tenths millimetres to two millimetres in length, 
the male being somewhat smaller. The darker the skin of the person 
infested the darker is the color of the parasites. So marked is this 
peculiarity that some writers are of the opinion that different species 
affect different races. The ova are grayish glistening specks enclosed 
in a membrane firmly adherent to the shaft of a hair not far from its 
root, and coming off at an acute angle, with the opening away from 
the scalp after the exit of this parasite. Considerable irritation is 
caused by these animals, and when this is severe the hair on the back 
of the head may be found matted with soft yellow crusts. The scalp 
is covered with moist red granulations. The cervical lymphatic glands 
posteriorly are enlarged. This condition is most frequently seen in 
children, (b) Pediculus pubis. — It differs slightly from the above in 
that it is smaller and infests regions, as the axillary, the pubic, and 
the periocular, where the hair is short, (c) Pedicidus corporis is the 
largest form of the parasite. It lives in the clothing, when not in search 
of food on the body. By its constant irritation it causes dermatitis, 
and if present for a long time, pigmentation and thickening of the skin. 
id) Cimex lectularius (common bedbug), (e) Pulex irritans (the 
common flea). ( f) Pidex penetrans (sand-flea, jigger). The latter 



POST MOkTKM KXAMINATIONS 

is common in tropical and subtropical countries. It is smaller than 
the common flea. It burrows under the skin and produces a pustular 
s\\ elling. (g ) Sarcoptes (Acarus) scabiei. — The female itch-mite is .45 
of a millimetre long and ,35 of a millimetre broad; the male is about 
half the size. Its color is pearly white. The burrow in the skin, 
wherein may lie found the excrement and the eggs of the parasites, 
is about one centimetre in length, and is present where the skin is 
moist, as in the webs of the fingers and toes. Cutaneous lesions result 
from the scratching instigated by the irritation caused by the parasite. 
Cestodes. — Intestinal Cestodes. — (a) Taenia solium in the ma- 
ture form may reach to twelve feet or even more in length. It is 
composed of numerous segments about one-third of an inch long and 
averaging a fourth of an inch wide. The head is very minute, being 
no larger than the head of a pin. In front is a rostellum and at the 
base of this is a fringe of hooklets. It has four suckers. The worm 
is hermaphroditic. When mature thousands of ova are passed by the 
rectum. The embryo has six hooklets. It penetrates the walls of the 
st( 'mach and burrows into the tissues of the animal that has swallowed 
it. (b) Tccnia saginata is larger, longer, and of more frequent occur- 
rence than the preceding. The head is nearly square and measures 
more than two millimetres in breadth, but has no hooklets. The seg- 
ments are larger than those of the Tccnia solium. The reproductive 

us are on the ventral aspects of the segments in the median lines. 

The BothrioccpJialus lotus is larger and longer than any of the 
flat worms. In the mature state it is twenty-five feet or more in length. 
It has no hooklets, but is furnished with slit-like fossae on the head, 
which act like suckers. The larvae develop in the peritoneum of fish. 
(ci ) Tccnia flavo punctata is very rare. It is about sixteen centimetres 
j. \c) The Cysticercus celluloses is the larval form of the Tcenia 
solium. \t is found in the muscles, brain, cord, peritoneum, or almost 
any other tissue of the affected animal. The surrounding capsule is 
frequently calcified. In the making of many autopsies it is surprising 
how few taenia are found in the intestinal tract. My experience is lim- 
ited to but two cases. One of these was that of a man who committed 
suicide with opium. Two Tccnicc saginatcc were found, the head of the 

one being firmly attached beneath a fold of one of the valvulae 

iventes high up in the jejunum and the other five or six feet far- 
ther down the intestine, the segments of both worms then continuing 
on down to near the ileocecal valve. 



PARASITIC DISEASES 



321 



Nematodes. — (a) Ascaris Lumbricoidcs. — It is a cylindrical 
worm with both ends pointed. The female is from ten to sixteen 
inches in length, the male considerably smaller. It is brownish yellow, 
reddish, or white in color. The head ends in three lips, (b) The 
Oxyurus vermicularis (seat-worm) is a very small round worm, about 
ten millimetres long, (c) The Trichina spiralis in the mature state 
lives in the intestine; in the immature state in the muscles. The em- 
bryo is surrounded by a capsule, which quickly calcifies. Under the 
microscope the embryo can be seen coiled up in its capsule; it is less 
than a millimetre in length, (d) The Anchylostomum duodenale 
lives in the upper part of the intestine. The female is the larger, and 
varies from ten to sixteen millimetres in length. At the anterior por- 
tion of its head are hooklets, with which it attaches itself to the intes- 
tinal walls. It is frequently associated with Egyptian chlorosis. Stiles 
and Harris have recently called attention to the wide distribution of 
uncinariasis in the South; the disease may be readily recognized by 
finding the ova in the faeces, (e) The embryo of the Filaria sanguinis 
hominis is a round worm one-seventy-fifth to one-one-hundredth of an 
inch long. It is enclosed in a delicate sac. It circulates freely in the 
blood, but only at night. The adult parasite is located in the lym- 
phatic vessels and is three or four inches in length. According to 
Manson, it is introduced into the body by the mosquito. 

Distomiasis. — (a) Liver-flukes. (b) Blood-flukes. These 
worms are lanceolate in shape, quite flat, and possess a distinct head 
and neck. They are three-fourths of an inch long and about half an 
inch broad. The color is dull brown. The female blood-fluke has a 
grooved channel posteriorly for the reception of the male. They have 
two suckers, one near the mouth and the other near the ventral portion 
of the body. The liver-fluke infests the upper intestine and the bile- 
ducts. It causes the " liver-rot" in sheep. The blood-fluke is found 
chiefly in the portal system and the veins of the bladder. The ova 
may be seen in the urine as elongated ovoid bodies, sharply pointed at 
one extremity, and containing black pigment. They can easily be 
seen with a low power of the microscope. Parasitic haemoptysis now 
occurs in America as well as in Asia, and is due to the Paragonimus 
Westermanii. The eggs are found in the sputum, the fluke measuring 
from eight to sixteen millimetres long by four to eight millimetres 
across. 

Myiasis. — By this term is meant a condition in which a diseased 



, 22 POST-MORTEM EXAMINATIONS 

part becomes " living," as it is called. It is caused by the larvae of 
certain flesh-flies, of common house-flies, or of the bot-flies of oxen or 

■>. The ova of these flies may he deposited in the nostrils, ears, 
conjunctiva, open wounds, or even in the vagina during the puer- 
perium. 

Echinococcus Disease. — A parasitic disease, found most fre- 
quent ly in those countries, as Iceland and Australia, where the dog 
lives in intimate association with man; it is characterized by the 
formation of endogenous or exogenous multilocular cysts in various 
portions of the body. The Tcunia echinococcus is a very small, thread- 
like tapeworm (length from three to six millimetres), having only 
three segments. The head has four suckers, a rostellum, and a double 
row of hooklets. The adult worm is found in the dog. The embryos 
(scolices) are found in the ox, hog, sheep, horse, and man. Distribu- 
tion in Man. — (a) Liver (most common), (b) Lung and pleura, 
(c) Intestinal tract, (d) Kidney, brain, etc. The embryo, freed from 
the cyst by digestion in the stomach, burrows through the intestinal 
wall and is carried to the various organs; it then loses its hooklets 
and is gradually converted into a cyst (hyatid) having two walls, ex- 
ternal laminated, internal granular or parenchymatous, containing 
blood-vessels and muscle-fibres. The interior is filled with a clear non- 
albuminous fluid, specific gravity 1005- 1009, usually containing sugar 
and hooklets. From irritation of surrounding tissues a fibrous capsule 
generally develops on the outside. The cysts vary in size from that of 
a small pea to that of a child's head. From the inner (parenchyma- 
tous) layer may develop brood capsules, which in their turn produce 
numerous scolices. The cysts grow slowly; when the embryo dies, 
the whole becomes calcified. Sometimes the cysts suppurate; occa- 

ally they rupture into adjacent structures. 

H^MATOZOA. 
Malaria. — This widely distributed and much-studied disease is 
due to a true haematozoon, transmitted to man by the bite of the ano- 
pheles mosquitoes. Three varieties have been described: (a) Tertian. 

(b) Quartan. ( c) yEstivo-autumnal. Classification. — (a) Acute ma- 
larial fever, which may be quotidian, tertian, or quartan, (b) Per- 
nicious malaria. ( c) Chronic malarial cachexia. In the blood of the 
cadaver the plasmodium is seldom visible, "but it may be found in sec- 
tions of the brain, liver, and spleen. ( 1 ) Cases of simple malarial fever 



h;ematozoic diseases 323 

are rarely fatal. The blood shows disintegration of red corpuscles and 
an accumulation of pigment is thereby formed. The spleen is enlarged, 
dark in color, and may show pigmentary deposits. (2) In pernicious 
malaria the blood contains enormous numbers of the parasites. The 
red corpuscles are in all stages of destruction and the serum is tinged 
with haemoglobin. The spleen is moderately enlarged. The pulp is 
soft, chocolate-colored, and turbid; it contains large numbers of red 
corpuscles and parasites and the amount of pigment is greatly in- 
creased. The liver is swollen and presents areas of focal necrosis and 
capillary thrombosis. Pigmentary deposits are also common. The 
kidneys present more or less parenchymatous change with only mod- 
erate pignientation. (3) In malarial cachexia the blood presents all 
the characteristics of an advanced anaemia, 'often distinguishable from 
pernicious anaemia only by the presence of the parasite and icterus. 
The spleen is greatly enlarged : it may weigh from seven to ten pounds. 
The organ is firm and resistant to the knife. The capsule is thickened 
and the parenchyma brownish or slate-colored, with areas of pigmen- 
tation. The kidneys are enlarged and of a grayish-red color. The 
peritoneum is thickened, opaque, and of a deep slate-color ; the gastric 
and intestinal mucous membrane may have the same hue. The gray 
matter of the brain is of a deep reddish-gray color or in very chronic 
cases a chocolate-brown. The meninges are congested. (4) Among 
accidental and late lesions is cirrhosis of the liver. Very extensive 
pigmentation may occur. Pneumonia is believed to be common ; mod- 
erate albuminuria is frequent; acute nephritis is not uncommon; 
chronic nephritis may follow long-continued or repeated infection. 
Rupture of the capsule of the spleen may occur, followed by bleeding 
into the peritoneum and even peritonitis. In pernicious malaria the 
brain may show thrombosis, due to the parasites, with secondary soften- 
ing of the surrounding tissue. The same thing may be found in the 
gastro-intestinal mucosa and be followed by superficial ulceration. 
There may be advanced fatty degeneration of the heart. 

Psorospermosis. — A condition produced by the presence of oval, 
transparent bodies belonging to the coccidia, to which class the mala- 
rial organism also belongs. I. (1) In the majority of cases of the 
internal form the psorosperms have been found in the liver. (2) 
Whitish growths resembling tubercles and containing the coccidia 
have been found upon the peritoneum, omentum, and pericardium. 
(3) Similar masses are sometimes seen in the ileum, liver, spleen, and 



• 2 | POST-MORTEM EXAMINATIONS 

kidneys, The liver may be enlarged and contain caseous foci which 
surrounded by areas of congestion. (4) The spleen may be simi- 
larly affected. II. (1) In cutaneous affections the lesions closely 
resemble those of tuberculosis of the skin. They occur in Paget's 
ise of the nipple and by some are believed to be its cause. (2) A 
case has been reported in which at autopsy nodules were found in the 
lungs, adrenals, testicle, spleen, on the surface of the liver, and on 
the pleurae. Great numbers of psorozoa were found in the lesions. 
I 3 I Successful inoculations were made into rabbits and dogs. 

Trypanosoma. — Four animal diseases are caused by varieties of 
trypanosomes, nagana, surra, mat de caderas, and dourine. Recently 
Nepveu, Button, and others have found them in man, and the sleeping 
sickness and the so-called trypanosoma fever (probably different 
stages of the same disease) are due to the entrance into the blood and 
cerebrospinal fluids of Trypanosoma gambiense. These organisms 
arc transmitted to human beings by tsetse flies (Glossina palpalis). 
M«»nkcvs, dogs, cows, horses, and rats are also susceptible to certain 
species. Trypanosoma Lezvisi infests the rat and is transmitted by fleas 
and lice. Trypanosoma Evansi, Brucei, and Equinum equiperdum 
attack horses and the Trypanosoma disea infests birds. The tsetse 
fly carries the human parasite and the T. Brucei. These parasites are 
flagellated protozoa, fusiform in shape, several times larger than a 
blood-corpuscle. On one side is an undulating membrane, which ex- 
tend^ from the centrosome along the margin to the anterior end of 
the body, where it becomes a true flagellum. The parasite is non- 
sexual, reproducing by longitudinal division. It lives in the blood 
serum and attacks the red cells. The tsetse fly can carry the infection 
from sick to healthy up to forty-eight hours after having fed. Lately 
artificial cultivation of the Trypanosoma Lewisi from the rat to the 
hundredth generation has been made by McNeal and Novy. 1 Thus, 
the first strictly pure cultures of a pathogenic animal parasite have 
been obtained. The agglutination reaction occurs under proper con- 
ditions Coplin 2 showed these organisms from Blockley rats, and 
also a slide of the lungs showing pneumonic changes. Ehrlich and 
Shiga, experimenting with the organism, found that the stain trypan 
red was able to destroy the trypanosomes in mice and to protect them 



1 Vaughan's Dedication Volume. 

2 Phila. Path. Soc, December 10, 1903. 



HJEMATOZOIC DISEASES 325 

against relapses. This stain they found equally effective when given 
by way of the stomach. The stain is the combination of one mole- 
cule of tetrazotized benzidin monosulphate and two molecules of 
sodium naphthylamindisulphate. The skin is well reddened in eight 
minutes, reaches a maximum color in twelve hours, and tint remains 
for from six to eight weeks, longer in the internal organs. This stain 
has little or no effect on rats, guinea-pigs, or dogs. 1 The Leishmann- 
Donovan bodies were first found in the spleen. The parasites are by 
no means uncommon in the tropics, and are situated intracellularly in 
large mononuclear macrophages. Rogers has recently announced that 
trypanosomes develop upon culture of these bodies. 

1 Bcrl klin. Wchnschr., 1904, March 28, p. 329, and April 4, p. 362. 



CHAPTER XXII 

rill. PRESERVATION OF TISSUES FOR MICROSCOPIC AND MACROSCOPIC 

PURPOSES 1 

When tissues are to be preserved for microscopic study, the 
method of fixing and hardening them should be decided upon at the 
time of their removal from the body. The object to be obtained by 

fixation and hardening is permanently to solidify the structural ele- 
ments of a part as nearly as possible in their original form and situa- 
tion. All our present methods, however, fail to give an accurate 
picture of the living cell, and not enough attention is now paid to the 
microscopic examination of unstained fresh scrapings removed during 
the performance of the autopsy. The use of as perfectly fresh tissues 
as possible is essential, for many structural details disappear on 
molecular death. Fortunately, this does not occur until several hours 
after molar death, so that it is often possible to obtain tissues to all 
intents and purposes still living. Special attention should be paid to 
those tissues which have been stained or hardened by reagents during 
the lifetime of the body under examination, as the experimental stain- 
ing of tissue during life affords a most inviting field of original in- 
vestigation. 

The method of wrapping tissues in paper or cloth and transporting 
them to a distance is only to be regarded as a last resort. When this 
is done, pieces of sufficient size to insure preservation of their interior 
intact are enveloped in an abundant supply of clean cotton (antiseptic 
gauze causes markings on them), moistened very slightly with a 
bichlorid-tablet solution, and thoroughly protected from pressure; 
these segments are cut down to a proper size before they are put into 

1 Based on the works of Lee, The Microtomisfs Vade Mecum; Mallory and 
Wright, Pathological Technique ; Apathy, Die Mikrotechnik der thierischen Mor- 
phologic; Fischer, Fixirung, Fdrbung, und Bau des Protoplasmas; Szymono- 
. Lehrbuch der Histologic; Stohr, Text-book of Histology; Bohm and von 
Davidoff, Text-Book of Histology; Lehrbuch der Klinischen Untersuchungsmcth- 
oden, and the Jincyklopddie der mikroskopischen Technik, 1903. It is to be hoped 
that the ultramicroscope which will reveal particles with a linear diameter of .000001 
millimetre will render valuable service. Working with this instrument, Raehlmann 
C Deut. med. Wchnsch., March 24, 1904) found actively motile bacteria in the aqueous 
and vitreous humors of an eye enucleated for sympathetic ophthalmia. Zeiss has 
just put on the market the ultraviolet microscope. 
3^ 



PRESERVATION OF TISSUES 327 

the fixing agent in the laboratory. I sometimes cut the pieces in 
different shapes, each piece representing an organ or part, and always 
use the same shape for the same part. 

Bottles containing the more common fixatives should be ready, 
and as soon as the tissues are exposed and described — before the part 
becomes distorted, fluids escape, or surfaces dry — they should be cut 
with a clean, sharp knife into pieces about two centimetres in length 
and breadth and one centimetre thick. Sections of organs should in- 
clude their characteristic structures, — cortex, capsule, hilum, endocar- 
dium, etc. Sections of tumors should be taken from the centre, where 
degenerative changes are most marked, and from the growing periph- 
eral margin, if possible including some normal tissue; this is of espe- 
cial importance in the case of malignant tumors. Mucous and serous 
membranes are pinned out on cork, or wood that will give no stain 
when soaked in the preservative fluid to be used, with their secreting 
surfaces uppermost. Muscle-fibres are best preserved by being tightly 
stretched upon and tied at the ends of a piece of wood. The segments 
of tissue, without being touched by either fingers or forceps, are lifted 
on the blade of the scalpel and dropped immediately into a bottle con- 
taining an amount of fixing fluid far in excess of their bulk. Of 
energetic fixatives, such as Flemming's or Hermann's, about fifteen 
times the volume of the object introduced will suffice, while of milder 
fluids, like the bichromate of potassium or picric acid solutions, fifty 
times such volume should be employed. 

If the different tissues are distinguishable macroscopically, they 
may be placed in the same jar ; if not, separate bottles are better. Tags 
may be attached, the writing being done with a lead-pencil, so as not 
to be acted upon by the usual preservatives. The jars are labelled with 
the date, the number or name of the autopsy, and the fixative used. 
It is often of importance to add the exact locality from which the 
pieces have been removed and the plane on which they are to be cut 
when placed in the microtome. 

The fluid should always be changed after it becomes turbid ; or 
in the case of alcohol or formalin, preferably after three hours, whether 
it is turbid or not. If the specimens are to be sent away, they should 
not go until the fluid remains clear; if the time necessary for trans- 
portation exceeds that of the proper action of the fixative, they should 
be worked on up to 80 per cent, alcohol and shipped in that fluid, firmly 
packed in absorbent cotton. 



. 2 g POST-MORTEM EXAMINATIONS 

The choice of a fixing agent is determined by the nature of the 
object to be preserved and the purpose for which the investigation 
is undertaken. The characteristics of different pathologic conditions 
are better brought out in some fixatives than in others. Thus, fatty 
degenerations are well preserved by an osmic acid, bichromate, or 
formalin solution; (edematous and parenchymatous changes, by cor- 
rosive sublimate; fibrin and hemorrhagic conditions, by absolute alco- 
hol, etc. Moreover, different tissues require different treatment; the 
fixation of a lymph-node is quite a different matter from that of a 
retina. Then the purpose for which the examination is made will 
largely influence the choice. If it be simply a question of general 
diagnosis, Orth's fluid and alcohol will answer every purpose; by 
the use of alcohol we can preserve the specific staining properties of 
micro-organisms and haemoglobin and various important chemical re- 
actions, and by the use of Orth's fluid colloid and mucoid material 
retain their transparency, fat is preserved, etc. If we undertake the 
investigation of pathologic processes and the comparison of abnormal 
with normal cellular anatomy, then special fixatives must be used. 

The advantages and disadvantages of the fixing solutions most in 
use will first be given, next a list of pathologic conditions and the solu- 
tions best calculated to preserve their characteristics, and finally a list 
of staining solutions requiring certain fixatives for their use. 

Fixatives; Insolubility.- — To preserve soluble cell contents they 
must first be rendered insoluble, and the transformation must be equable 
throughout. The colloid or fluid material must harden homogeneously 
and enclose the more solid structures without loss of former relation- 
ship : there must be no shrinkage, no condensation, no expansion ; but 
everything should be precisely as it was when manifesting vital activi- 
ties, except this change into a compound that will remain undissolved 
and persist through subsequent necessary manipulations. This insolu- 
bility is supposed to be due in some cases to a sort of clotting process; 
and if the coagulating property be stronger in absolute alcohol than its 
dehydrating power and less in alcohol of lower percentage, this fact ex- 
plains why more shrinking is caused by 96 per cent, than by absolute 
alcohol, and why the shrinking increases with the lowering of the 
alcoholic strength. Other fixing agents, such as osmic acid, chromic 
acid, potassium bichromate, and corrosive sublimate solutions, seem 
to form a chemical union with the cell contents and so produce an 
extremely durable insolubility. Others, such as picric acid and nitric 



PRESERVATION OF TISSUES 



329 



acid, harden well, but form such unstable compounds that the fixation 
is easily removed by washing in water and must be preserved by 
placing the specimens in alcohol. It is evident that any solvent action 
bv the reagent — e.g., the action of alcohol on fat and that of acetic 
acid on protoplasm — lessens their practical value. 

Optical Differentiation. — Some agents in producing insolu- 
bility effect another change which is equally valuable and which is 
known as optical differentiation. The various cell structures respond 
differently to the fixative. Their indices of refraction are altered; 
some are raised, some lowered, and marked contrasts in refractive 
properties are developed throughout the cell. In this way structures 
become visible that were before unseen. Bichromate of potassium 
stiffens very equably, with neither shrinkage nor expansion, but has 
no power of optical differentiation; while osmic acid possesses this 
in a high degree. Since observation with the microscope is directly 
dependent upon differences in refraction, it is evident that this is a 
most valuable property of a fixative. 

Penetration. — The ability to reach all points of the tissue at the 
same time is another important characteristic of a fixing agent and 
one clearly connected with securing optical differentiation. Osmic 
acid has but little penetration. If pieces placed in its solutions are 
too thick or remain therein too long, the superficial layers become 
over-exposed, the indices of refraction are all equally raised, and 
differentiation disappears. This is true not only of cells in mass, but 
also of intracellular structures. Prompt and uniform action, the sharp 
fixation of tissues at the precise moment, insures good optical differ- 
entiation ; slow, unequal action results in loss of definition. 

Fixing Fluids. — All acids apparently possess fixing properties, 
and every fixing fluid should be acid, with possibly the exception of 
alcohol. Of the organic acids acetic and formic are those most used ; 
of the inorganic, nitric, sulphuric, picric, hydrochloric, osmic, and 
chromic. 

Acetic Acid. — By this term is always meant glacial acetic acid, 
which has very great penetrating power and aids in optical differen- 
tiation. It causes swelling and solution of protoplasm, and hence is 
not used alone, but with fixatives such as osmic acid to aid in penetra- 
tion and prevent excessive blackening, with alcohol and corrosive sub- 
limate to prevent shrinkage, and with chrome salts to aid in optical 
differentiation. It is usually added to these various solutions in 



» 3 o POST-MORTEM KXAMINATIONS 

strengths varying from 0.5 to 5 per cent. All liquids containing a 
large percentage of acetic acid should be allowed to act only for a 
short time. Acetic acid should not be used for connective tissue. 

Alcohol (95 per cent, or absolute; 2-24 hours; 5 mm. thick). — 
Alcohol has certain important advantages. It can be readily procured, 
does not have to be made up, tissues are hardened as well as fixed 
by it. and. since it represents one of the last stages preparatory to. 
embedding, its use saves much time and trouble, and the material for 
a general diagnosis is easily and promptly prepared, which is often 

real convenience. It penetrates well, preserves the specific staining 
properties of micro-organisms and various important chemical reac- 
tions, permits the use of most stains and is demanded by others, — 
e.g., Nissl's, Lenhossek's, Weigert's, Ribbert's phosphomolybdic hsema- 
toxylin. I nna's orcein, etc. It is especially good for glands, skin, 
and blood-vessels, mastcells, plasma cells, fibrin, and hyperaemic con- 
ditions, since it preserves the color-reactions of haemoglobin. On the 
other hand, it sometimes causes shrinkage and exerts a bad solvent 
action, so that the cells come out lean and empty, with foamy, vacuo- 
lated protoplasm and with distortion or loss of original structure. 

Tissues should not remain too long in absolute alcohol, as they 
si >metimes stain very poorly after as short a time as twenty-four hours. 
Alcohol is not a good fixative for van Gieson's stain. Alcohol of 
lower percentage than 95 causes excessive shrinkage. 

The shrinkage of alcohol is corrected by the use of acetic acid. 

Carnoy's fluids (for nuclear structures) : 

1. Glacial acetic acid i part. 

Absolute alcohol 3 parts. 

2. Glacial acetic acid 1 part. 

Absolute alcohol 6 parts. 

Chloroform 3 parts. 

Leave pieces in for from fifteen to thirty minutes; wash out in alcohol. 
Avoid aqueous liquids. 

(For acetic alcohol with sublimate see " Gilson's solution" and 
" Ohlmacher's solution" under Corrosive Sublimate.) 

r the use of alcohol as a fixing agent, tissues must either be 
eYnbedded in celloidin or paraffin as soon as hardened or left in cedar 
nil, or put through 95 per cent, alcohol and finally preserved in 80 per 
cent. 

Chromic Acid. — Chromic acid is a powerful and rapid coagulating 



PRESERVATION OF TISSUES 33 T 

agent, but, on account of its lack of penetration and tendency to cause 
shrinkage and make tissues brittle, it is seldom used alone. Its de- 
fects are remedied by adding acetic, formic, osmic, or nitric acid to 
its solutions. All tissues fixed by chromic acid solutions are to be 
washed in running water and hardened in graded alcohols in the dark. 
Chromo-acetic acid (Rabl) : 

Acetic acid, o.i per cent, in water I part. 

Chromic acid, from 0.2 to 0.25 per cent 1 part. 

Chromo-formic acid (Rabl) : 

Chromic acid, 0.33 per cent 200 cc. 

Formic acid, concentrated from 4 to 5 drops. 

Use at once, fix for from twelve to twenty-four hours. 
Chromo-nitric acid (Perenyi) (4-5 hours) : 

Nitric acid, 10 per cent 4 parts. 

Alcohol 3 parts. 

Chromic acid, 0.5 per cent • 3 parts. 

Transfer directly to 70 per cent, alcohol for twenty-four hours, to 95 
per cent, for some days, and to absolute alcohol from four to five days. 

Chromo-osmic acid has been superseded by 

Chromo-aceto-osmic acid (Flemming) : 

Chromic acid, 1 per cent 45 cc. 

Osmic acid, 2 per cent 12 cc. 

Glacial acetic acid 3 cc. 

Objects may stay in this solution for hours or even several days. The 
pieces should be perfectly fresh and not thicker than 4 mm. 

It should be made up shortly before using. When all the condi- 
tions are fulfilled, it is unequalled as a fixative and in producing optical 
differentiation. The most delicate structural details are brilliantly 
shown. Especially used for mitotic figures. 

Bichromate of Potassium. — The simple aqueous solution is used 
in gradually increasing strengths from 2 to 5 per cent, for harden- 
ing purposes, for which it is excellent, but, on account of its lack of 
penetration and tendency to cause the chromatin to swell, it is not 
suitable for a nuclear fixing agent without being reinforced. The 
addition of glacial acetic acid gives a fluid which acts nearly as well 
as Zenker's and is much more convenient to use. The excess of bi- 
chromate is to be well washed out in running water and the tissues 
hardened in alcohols in the dark. 



,, 2 POST-MORTEM EXAMINATIONS 

Acetic bichromate (Tellyesniczky) (1-2 days): 

Bichromate of potassium 3 grammes. 

Glacial acetic acid 5 cc. 

Water IOO cc. 

Begin hardening with 1 5 per cent, alcohol. 

Osmic, bichromate, and platinum chlorid (2 hours) (Dr. Lindsay 
Johnson ) : 

Potassium bichromate, 2.5 per cent 70 parts. 

Osmic acid, 2 per cent 10 parts. 

Platinic chlorid, 1 per cent 15 parts. 

Acetic or formic acid (just before using) 5 parts. 

A fine fixative for delicate objects, such as a retina. Leave objects in 
for two hours. Wash in running water. Harden in alcohol. 

The slow, mixed, and rapid methods of Golgi stain the cells with 
their prolongations, the nerve-fibres with their terminal ramifications, 
and the neuroglia cells. 

Golgi's slow method : Harden pieces of tissue in a 2 per cent, 
solution of bichromate of potassium from two to six weeks. Keep in 
the dark and change often. Transfer to a 0.75 per cent, aqueous solu- 
tion of silver nitrate. 

Golgi's mixed method: Harden small pieces of tissue for from 
three to five days, or longer, in a 2 per cent, solution of potassium 
bichromate at 25 ° C. in the dark. Place in the following solution for 
from three to eight days. 

Osmic acid, 1 per cent 2 parts. 

Bichromate of potassium 8 parts. 

Then into a 0.75 per cent, silver nitrate solution. 

Golgi's quick method : Tissues should be absolutely fresh, and the 
pieces not more than three millimetres thick. 

Osmic acid, 1 per cent : 1 part. 

Bichromate of potassium, 3.5 per cent 4 parts. 

Leave pieces of neuroglia in the solution for two or three days, nerve- 
cells from three to five days, nerve-fibres and collaterals from five to 
days. Then place in 0.75 per cent, silver nitrate solution. 
Mullcr's fluid (6-8 weeks) : 

I.ichromate of potassium 2.5 grammes. 

Sulphate of sodium 1. gramme. 

Water 100. cc. 



PRESERVATION OF TISSUES 333 

This fluid, once so universally used, is now largely replaced by 
better fixatives. It has all the faults of the plain bichromate solution 
and the same need of being reinforced. (For acetic acid and sub- 
limate additions see " Zenker's fluid" under Corrosive Sublimate; for 
formalin see " Orth's fluid" under Formalin.) It hardens evenly 
without shrinkage and gives very good consistency to tissues, but it 
is in no way a nuclear fixative. As a hardening agent for nervous 
tissue it has been almost entirely replaced by formalin. 

Pieces of tissue not larger than two centimetres are hardened in 
from six to eight weeks. Change daily for seven days, then once a 
week. Wash in running water twenty-four hours. Nervous tissue 
is placed directly in alcohol. 

Erlicki's Solution. — 

Potassium bichromate 2.5 grammes. 

Copper sulphate 0.5 to 1. gramme. 

Water 100. cc. 

This is an extremely good agent for hardening voluminous ob- 
jects. Its action is much more rapid than that of Mutter's fluid. For 
microscopic work, however, it gives precipitates likely to be mislead- 
ing and difficult to remove. It is used as a fixative for Freud's gold 
stain for nerve-fibres. 

Chlorid of Iron (Mallory) (3-5 days). — For peripheral nerve- 
fibres. 

Chlorid of iron 1 part. 

Distilled water 4 parts. 

Wash out thoroughly in water. Transfer to a saturated solution of 
dinitroresorcin in 75 per cent, alcohol for several weeks. Wash, 
dehydrate, etc. 

This stain may be used after Flemming or Miiller. 

Corrosive Sublimate (Bichlorid of Mercury). — This is a very 
active penetrating and hardening agent, and since tissues are suffi- 
ciently affected by it in from three minutes to two hours and are then 
placed directly into alcohol, the process is a quick and convenient 
one. Carmin and van Gieson stains are particularly brilliant after 
it. The Heidenhain-Biondi triple stain requires its use. It is an 
especially good fixative for the alimentary tract; for cedematous tis- 
sues and albuminous degenerations, since it coagulates nearly as well 
as boiling water; it is used for connective-tissue fibrillar with Mai- 



J34 POST-MORTEM EXAMINATIONS 

lory's anilin-blue stain. Its disadvantages are that it causes shrink - 
and the formation of precipitates which must be removed. If 
tissues are too long exposed to its action they become brittle, and if 
kept too long in alcohol they are very difficult to cut. Unless corrected 
by the addition of some other agent, poor optical differentiation is 
obtained, so that corrosive sublimate should be used only for general 
and not Tor cytological work. Pieces of tissue should not be larger than 
live millimetres, and must be removed as soon as they become thor- 
oughly opaque, otherwise they will be too brittle. All solutions con- 
taining this salt act much better when freshly made, as they deteriorate 
by standing. 

Sodium chlorid and bichlorid of mercury (Heidenhain's solution) : 
A saturated solution of bichlorid of mercury in 0.5 per cent, solution 
1 >f sodium chlorid. 

Aeetic sublimate: A saturated solution of corrosive sublimate in 
5 per cent, glacial acetic acid. 

Gilson's solution : 

Absolute alcohol 1 part. 

Glacial acetic acid 1 part. 

Chloroform 1 part. 

Sublimate to saturation. 

This liquid is one of the most penetrating and rapidly acting of any, 
if not the most. Wash out with alcohol containing tincture of iodin. 
Ohlmacher's solution (15-30 minutes) : 

Absolute alcohol 80 parts. 

Chloroform 15 parts. 

Glacial acetic acid 5 parts. 

Sublimate to saturation (about 20 per cent.). 

A cerebral hemisphere sectioned by Meynert's method is hardened in 
from eighteen to twenty- four hours. 
Zenker's fluid : 

Corrosive sublimate 5 grammes. 

Glacial acetic acid 5 cc. 

Mutter's fluid 95 cc. 

Add the sublimate and acetic acid just before using. Leave tissues 
in from twenty-four to forty-eight hours. 

This fluid is comparable to that of Flemming in perfect fixation. 
ft has better penetration, over-fixation is not so likely to occur, it gives 
better staining results, and is much cheaper. It is altogether most 



PRESERVATION OF TISSUES 335 

satisfactory. Eosin stains are especially brilliant after its use. Its 
one disadvantage is that the sublimate must be removed by placing 
sections in 70 per cent, alcohol containing enough tincture of iodin 
to give it the color of a dark sherry wine; but this is true of all sub- 
limate solutions. 

Bensley's solution ( J />-2 hours) : 

Potassium bichromate, 1 to 2 per cent, solution in water. . 1 part. 
Corrosive sublimate, saturated solution in alcohol 1 part. 

Mix the two solutions just before use. Leave tissues in from one- 
half hour to two hours. Wash well in water. 

This solution is especially useful for the gastro-intestinal tract. 

As sublamin, 1 the ethyldiaminsulphate of mercury, forms no pre- 
cipitates, tissues are easily stained after its use, and preserve to a 
certain extent their natural color. 

Formalin. — This agent acts very rapidly; it causes little shrinkage. 
Cytoplasm and nuclei are well preserved. Mitotic figures are fixed. 
Haemoglobin and micro-organisms retain their specific staining re- 
actions. Fat is not dissolved; mucin is not precipitated, but remains 
transparent. Formalin is an especially valuable fixative for nervous 
tissues: an entire brain may be hardened in a 10 per cent, solution 
in from a week to ten days. It gives great toughness and elasticity 
to tissues, and is required for many methods of staining nerve-fibres. 
Pieces of nerve tissue ten millimetres thick may first be fixed in for- 
malin and then subjected to the action of any mordant desired. 2 

It is used in a standard solution of ten cubic centimetres of for- 
malin to ninety cubic centimetres of distilled water. Change after 
three hours. Tissues are fixed in from one to two days, but may re- 
main in the fluid indefinitely if the percentage of formalin is main- 
tained. 

Orth's fluid ( 1-2 days) : 

Potassium bichromate 2.5 parts. 

Sodium sulphate 1. part. 

Water 100. cc. 

Formalin 10. cc. 

Add the formalin just before using. 

1 Klingmuller AND Veiel, Ccntralh. f. allg. Path., 1903, vol. xiv, no. 20, p. 842. 
1 For the effect of formalin on tissues see Jr. Am. Med. Assoc, March 12, 1904, 
p. 734 and September 3, 1904, p. 685. 



-,, POST-MORTEM EXAMINATIONS 

This is Miiller's fluid with 10 per cent, formalin. It is one of the 
best general fixatives in use. 

Nitric Acid (3 per cent. ; 6 hours; 70 per cent, alcohol). — It gives 
toughness to tissues and is especially suitable for organs rich in con- 
nective tissue. Bichromate of potassium may be used after fixation 
in nitric acid. 

Osmic Acid. — This is one of the finest fixatives known, especially 
for cytoplasm. It has great power of rendering cell constituents in- 
soluble and of developing optical differentiation, thus bringing to 
view structures previously unknown. As it has very little penetration, 
superficial cells may be overfixed and homogeneous. Carmin stains 
badly after its use, but hematoxylin is not affected. It is seldom 
used alone except for fixation by vapors. Very delicate objects are 
pinned out on the well-fitting cork of a wide-mouthed bottle and 
exposed to the vapors of a small quantity of a 1 per cent, solution 
poured into the bottle. A retina needs an exposure of some hours 
and is more equally fixed than when placed in the solution. Osmic 
acid solutions do not keep well and must be carefully protected from 
dust. Lee recommends a 2 per cent, solution in 1 per cent, chromic 
acid. This serves for vapor fixation and Flemming's solution. It may 
also be kept as a 1 per cent, solution in distilled water. (For Flem- 
ming's solution see " Chromo-aceto-osmic acid.") In making osmic 
acid solutions the capsule containing this acid is broken within the 
bottle containing the solution. Tellyesniczky x suggests as the best 
substitute for osmic acid the following: 

Potassium bichromate 3 grammes. 

Acidi aceti 5 cc. 

Aquae 100 grammes. 

Platinico-acetico-osmic-acid solution (Hermann's solution; 1-8 
days) : This celebrated reagent is Flemming's solution with platinic 
chlorid instead of chromic acid. 

Platinic chlorid, 1 per cent 15 parts. 

Glacial acetic acid 1 part. 

Osmic acid, 2 per cent 2 to 4 parts. 

Its action is comparable to that of Flemming's solution. The most 
delicate structures are faithfully preserved and well shown. 

1 Arch. f. mikrosk. Anat., 1898, vol. Hi, p. 202. 



PRESERVATION OF TISSUES 



337 



Pianese's solution (36 hours) : 

Chlorid of platinum and sodium, 1 per cent, aqueous 

solution 15 cc. 

Chromic acid, 0.25 per cent, aqueous solution 5 cc. 

Osmic acid, 2 per cent, aqueous solution 5 cc. 

Formic acid, C. P 1 drop. 

For karyokinesis and the so-called cancer bodies. Pieces of tissue 
must not be more than two millimetres thick. It gives very inter- 
esting results histologically. 

Picric Acid (2-24 hours). — Picric acid is an extremely pene- 
trating and delicate fixative. It hardens very slightly, and the insolu- 
bility caused by its action may be easily .removed by washing in water ; 
hence its preparations should always be placed in alcohol. It is used 
as a saturated aqueous solution and in large quantity, — about one 
hundred times the bulk of the object. It is an excellent fixative for 
delicate serous membranes, which may be floated in it without retrac- 
tion or distortion. The omentum and peritoneum are well fixed in it. 

Picro-acetic acid : A saturated solution of picric acid in one per 
cent, acetic acid ; a very good fixative. 

Picro-sulphuric acid (Kleinenberg) : Add 1 cc. of concentrated 
sulphuric acid to 100 cc. of a saturated aqueous picric acid solution. 
Let stand for nearly four hours ; filter ; add double its volume of dis- 
tilled water. This is an excellent fixative for delicate embryos. 

Picro-nitric and picro-hydrochloric acid solutions are also used, 
but their action is essentially the same as that of picro-sulphuric. 

The advantages of picric acid solutions are that they give a very 
delicate fixative with excellent cutting qualities, and delicate mem- 
branes are not thickened excessively as with stronger reagents. 

Hardening. — To give to tissues a proper cutting consistency they 
are gradually hardened by being passed through a series of graded 
alcohols. For general diagnosis tissues may go from water into 70 
per cent, alcohol, then 95 per cent., and finally absolute alcohol, usually 
remaining twenty-four hours in each grade. Corrosive sublimate and 
Golgi tissues are to be placed for only a few hours in 95 per cent, and 
absolute alcohols, without passing through the lower grades. For 
finer work begin with 30 per cent, or even 15 per cent, alcohol, then 
use 50, 70, 80, 95, and absolute. When the tissues are passed from 
a lower to a higher grade of alcohol, surplus moisture should be re- 
moved with blotting-paper to avoid lowering the percentage of the 
next grade. 



»,g POST MORTEM KXAMINATIONS 

Preservation. — After being fixed and hardened, tissues are usu- 
ally preserved in 80 per cent, alcohol. Those fixed by formalin may 
remain in a 10 per cent, solution thereof. Golgi preparations keep 
indefinitely in the silver nitrate solution. Corrosive sublimate tissues 
will not cut well if kept too long in any kind of alcohol; they had 
better be kept in cedar oil. A sugar formation takes place in liver 
preserved in alcohol, and certain peculiar changes may arise in the 
nervous tissue, especially if acted upon by sunlight. 

Pathologic Conditions suggesting Certain Fixatives. — Acute in- 
fectious processes: Alcohol. 

Acute inflammatory exudates: The fibrin, leucocytes, and red 
blood-corpuscles of hemorrhagic conditions are preserved especially 
well in Zenker's fluid. 

Albuminous degenerations: Corrosive sublimate, Zenker, or boil- 
ing water. 

Amoebae coli: Stain especially well with Mallory's chlorid of iron 
haematoxylin ; any fixative may be used except perhaps formalin. 
Amoebae coli may be studied either in the faeces or in the tissues. Col- 
lect the faeces in a perfectly clean dry vessel, warmed in cold weather, 
and keep them at the temperature of the room. Add a drop of a weak 
solution of toluidin blue to a particle of the faeces, make a cover-slip 
preparation, and preserve in Farrant's medium. For the tissues fix in 
Heidenhain's or Bensley's solution, stain with iron haematoxylin or with 
a weak solution of toluidin blue. If a contrast stain is desired, stain first 
with eosin or benzo-purpurin, then for fifteen or twenty minutes with 
a weak solution of toluidin blue; differentiate wdth alcohol. 

Amyloid degenerations: Corrosive sublimate, Zenker, alcohol. 

Blood: Make thin films; stain with a 0.5 per cent, solution of 
the eosinate of methylene blue in absolute alcohol. 

Bone: For infectious processes, alcohol; for histological purposes, 
Zenker, Orth. Bone must always be fixed before decalcifying. 

Bone marrow : Make smears on cover-slips. Fix pieces of bone 
marrow in Zenker or formalin. 

Cartilage : Alcohol, Zenker, Orth. 

Central nervous system: A whole brain may be hardened in about 
three thousand cubic centimetres of Midler's fluid. Change every day 
for a week, then every week for four weeks, and every two weeks 
thereafter; it takes about three months to complete the hardening. 
Keep in a refrigerator if the weather be very warm. Erlicki's fluid 



PRESERVATION OF TISSUES 339 

hardens better and its action is more rapid, hardening being accom- 
plished in about four weeks. 

In a 10 per cent, solution of formalin a whole brain may be hard- 
ened in from ten days to two weeks. Change the solution every day 
for three days, then every third day. Cerebral hemispheres may be 
sectioned by Meynert's method and hardened in twenty- four hours 
in Ohlmacher's solution. These methods are not recommended for 
fine work. Pieces not larger than one centimetre may be hardened 
in formalin and then subjected to any bichromate or osmic acid mor- 
dant, including Golgi's methods. 

Ganglion cells : For Nissl's method fix in 96 per cent, alcohol. 
For Lenhossek fix in 90 per cent, alcohol (or 10 per cent, formalin) 
and follow with 96 per cent, alcohol. For Golgi methods use Golgi 
fixatives. 

Myelin sheaths : For Weigert fix with 5 per cent, bichromate until 
" ripe/' — that is, until color contrasts between white and gray matter 
are well developed. For Marchi use Miiller's fluid. Use formalin for 
Busch-Mallory, Weigert, Weigert-Pal, and Heller. For Exner use 
1 per cent, osmic acid; change second day; leave pieces in for five 
or six days. 

Neuroglia fibres : These are not well preserved by chromates. For 
Weigert methods fix in formalin. For Mallory fix in ten per cent, 
formalin in a saturated aqueous solution of picric acid. 

Medulla, pons, and basal ganglia : They may be removed together 
en masse and hardened entire in formalin for from one to two weeks, 
then cut into parallel slices not over one centimetre thick, and mor- 
danted by Weigert's quick method or Mallory's or in any way de- 
sired. Golgi stains are not very applicable to the medulla. 

Axis-cylinders and their terminal processes : For Freud's or 
Stroebe's gold stain fix in Erlicki or Miiller. For Gerlach's method 
harden in 0.5 per cent, solution of bichromate of ammonium for from 
one to three weeks. (For Golgi see " Golgi methods" under Bi- 
chromate of Potassium.) 

Degenerated nerve-fibres : Harden in Miiller or Erlicki for Marchi 
or Algeri methods, or harden in 10 per cent, formalin followed by 
Miiller and Erlicki. 

Peripheral nerve-fibres: Fix in chlorid of iron. 

Retina: The retina may be fixed in a 10 per cent, solution of for- 
malin ; in Zenker's, Orth's, or Lindsay Johnson's solution, as given 



m POST-MORTEM EXAMINATIONS 

under Bichromate of Potassium; in equal parts of glacial acetic acid 
and osmic acid (2 per cent.) ; in equal parts of chromic acid and pla- 
tinic chlorid (each 1.4 per cent.) ; or it may be pinned out on a cork 
and exposed to the vapor of a 1 per cent, solution of osmic acid. 

Colloid material : Formalin or Orth. 

Connective tissue: For Ribbert's phosphomolybdic hematoxylin 
stain for fibrillae fix in alcohol. For Mallory's anilin-blue stain fix in 
corrosive sublimate or Zenker. 

Elastic fibres : For Unna's orcein method fix in alcohol. For Wei- 
gert fix in alcohol or formalin. 

Fatty changes: Flemming, Orth, Miiller, Erlicki, or formalin. 

Fibrin: For eosin hematoxylin, methylene blue, and Mallory's 
anilin-blue stain fix in Zenker or corrosive sublimate. For infectious 
processes and YYeigert's method fix in absolute alcohol. 

Glands : Fix in absolute alcohol. 

Granulation tissue: Fix in Zenker, Flemming, or Pianese for at- 
tendant degenerations. 

Hyaline degenerations : Zenker, corrosive sublimate, Orth. 

Liver: For pernicious anaemia and amyloid degenerations fix in 
alcohol. For bile capillaries use Golgi method. 

Mastcells : For Ehrlich's or Unna's methods fix in alcohol. 

Mucoid material : For Mallory's anilin-blue stain fix in Zenker or 
corrosive sublimate. For other stains use Orth or formalin. 

Myxomas : Zenker or corrosive sublimate. 

(Edematous conditions : Throw small pieces of tissue into boiling- 
water for a minute or two, or fix in corrosive sublimate. 

Ovaries : For follicular degenerations use Flemming or Hermann 
if tissues are fresh, if not use Zenker, Orth, Carnoy, or Ohlmacher. 

Pancreas : For Altmann's granules fix in equal parts of a 5 per cent, 
solution of bichromate of potassium and a 2 per cent, solution of osmic 
acid. 

Plasma cells : Zenker is especially favorable for showing eosino- 
phil es. 

Pus or purulent conditions: Orth, Zenker, or corrosive sublimate. 

Skin is best fixed in alcohol. 

Spleen : For Heidenhain Biondi triple stain fix in corrosive sub- 
limate. For eosinophiles or Ehrlich's triacid use Zenker or alcohol. 

Suprarenal : If fresh fix in Flemming or Hermann; if not, in Ohl- 
macher. Zenker, or Orth. 



PRESERVATION OF TISSUES 34I 

Thyroid : For colloid degeneration fix in Orth or 10 per cent, 
formalin. 

Fixatives. — The following list gives the fixatives used for the 
various stains. 

Alum hematoxylin : Stains very slowly after chromic solutions. 

Anilin blue (Mallory) : Succeeds best after Zenker or corrosive 
sublimate. It may be used after formalin. 

Biondi Heidenhain (see " Heidenhain Biondi"). 

Eosin and methylene blue : Best after Zenker. 

Freud's gold stain: For axis-cylinders and nerve terminals; used 
after Muller or Erlicki. 

Gold stains : Freud's, Stroebe's, after Muller or Erlicki ; Gerlach 
after 0.5 per cent, bichromate of ammonium for from one to three 
weeks. 

Golgi chrome silver preparation : After Golgi fixing solutions. 

Heidenhain Biondi triple stain : Only after corrosive sublimate. 

Lenhossek: For ganglion cells 90 per cent, alcohol or 10 per cent, 
formalin, both followed by 96 per cent, alcohol. 

Nissl : For ganglion cells 96 per cent, alcohol. 

Orcein (see " Unna's orcein stain"). 

Phosphomolybdic acid hsematoxylin: Best after alcohol. 

Phosphotungstic acid hsematoxylin: After 10 per cent, formalin. 

Thionin (Lenhossek's ganglion-cell stain) : 90 per cent, alcohol 
followed by 96 per cent, or formalin 10 per cent. 

Triple staining : Heidenhain Biondi only after corrosive subli- 
mate. 

Unna's alkaline methylene blue : Alcohol. 

Unna's orcein stain : For elastic fibres, alcohol. 

Weigert's stain : For fibrin and elastic fibres, absolute alcohol. 

Macroscopic Specimens. — If a microscopic examination of the 
organ to be preserved is desirable, portions of tissue therefor should 
be removed before anything is done towards preparing it as a gross 
specimen. 

If for any reason it be desirable to keep the specimen for a short 
time, it should be kept moist by being wrapped in cloths wet with 10 
per cent, formalin solution. Parenchymatous organs of slaughtered 
animals will keep for a week packed in this way and, when sectioned, 
the tissues appear fresh. The organs of deceased animals do not keep 
as well. If the specimen is to serve for a bacteriologic investigation 



. j j POST MORTEM EXAMINATIONS 

and for inoculations, it should not be wrapped in any disinfecting 
agent, but simply packed in parchment-paper or rubber cloth. 

By a percentage solution of formalin is meant such a dilution of 
the commercial 40 per cent, (which is sold as formalin) as will reduce 
it to the desired strength. For instance, ten cubic centimetres of 
commercial Formalin added to ninety cubic centimetres of water pro- 
duce a 10 per cent, solution of formalin or a 4 per cent, solution 
of formaldehyde. The percentage of formalin must be maintained, 
as it is quickly exhausted; when there is no odor of formalin, the 
fluid should be renewed. 

It is not always necessary to save the entire organ to be examined, 
but enough should be preserved to show its relationship to the lesion. 

General Considerations. — Washing. — If alcohol be used as the 
preserving solution, blood and other impurities may be removed by 
a thorough washing with water. In other cases the parts should be 
carefully sponged with the preservative to be employed. 

Cavities should be distended with tow or absorbent cotton. The 
lungs should be placed in a jar and the jar filled by pouring the fluid 
through the trachea. Mucous and serous membranes should be pro- 
tected from the distortion caused by shrinkage by being pinned out 
on cork or on wood which will impart no color in soaking. A more 
elegant method is to sew the membranes over the edges of frames 
made of glass rods. The secreting surfaces of these membranes should 
always be uppermost. 

Compression of any part of the specimen should be avoided by 
the use of a soft cushion of absorbent cotton placed in the bottom 
of the jar. Jars made especially for museum preparations are prefer- 
able, but if necessary they may be replaced by such as are used by 
grocers and druggists for candy, etc. 

Preserving Fluids. — Alcohol is a convenient and efficient agent. 
It preserves form relationships very well, as in tumors, typhoid ulcers, 
invagination of the intestine, etc.; but it destroys all contrasts in 
a pathologic organ, such as a diseased lung or kidney, and makes 
recognition of the lesion very difficult. It bleaches the tissues and 
causes much shrinkage, so that natural appearances are not retained. 
The specimen is to be washed in water, then immersed in 60 per cent, 
alcohol (which is changed every day until it remains clear), and finally 
kept in 80 per cent, alcohol. To preserve the natural appearance of 

ues, formalin followed by alcohol is used, and the specimen is 



PRESERVATION OF TISSUES 343 

finally placed in glycerin solution containing some salt of acetic acid, 
usually potassium. Formalin converts the haemoglobin into methaemo- 
globin and a brown color is developed ; alcohol changes the methsemo- 
globin into a red pigment, so that the flesh-color is restored. The 
tissues are so thoroughly hardened that they may be kept in the 
glycerin solution without being thereby softened. The principles 
involved are simple, but their application requires experience and 
ingenuity. All tissues do not respond equally to the treatment, and 
to retain some color peculiar to a certain pathologic condition — such 
as prevails in icterus, for example — requires careful management. 
There are various formulae and different methods of applying them, 
but the two following are perhaps as simple and useful as any. It 
must always be remembered that if the tissues are placed in too strong 
formalin, or remain too long even in a weak solution, the alcohol will 
fail to transform the brown or gray pigment back into red. 

1. Place the fresh organ or a segment as large as the hand for 
from twenty-four to forty-eight hours in one of the following solu- 
tions. 

Kaiserling fluid : 

Formalin 200 cc. 

Water 1000 cc. 

Potassium nitrate 15 grammes. 

Potassium acetate 30 grammes. 

Melnikow-Raswedenkow : 

Formalin 10. parts. 

Sodium acetate 3. parts. 

Potassium chlorate 0.5 part. 

Distilled water 100. parts. 

It is well to wrap the specimen in wadding and pour the fluid over 
it. The wadding protects the organ from distortion due to com- 
pression. If the organs are very thick, incise them or inject the blood- 
vessels, ureters, etc., with the fluid. This should be done very gently, 
in order not to wash out the blood. As formalin is injurious to the 
respirator}- tract and the skin, it is well when using it to wear rubber 
gloves and to keep the jars covered. 

2. After two days place the specimen in 60 per cent, alcohol, first 
removing the wadding. Two or three days later change to 80 per 
cent, alcohol, then to 90 or 93 per cent. 



> }) POST-MORTEM EXAMINATIONS 

3. The specimen is finally placed in the preserving fluid: 

Glycerin 400 grammes. 

Potassium acetate 200 grammes. 

Water 2000 grammes. 

The solutions may be used several times, but a fresh preserving 
fluid is better, and it is even advisable to change it occasionally. 

Pick adds at once to the formalin solution 5 per cent, of Carlsbad 
salts, which prevents the formation of acid hsematin, while Marpmann 
uses rluorsodium both in the formalin solution and in the glycerin. The 
use of ten parts of an 0.8 per cent, salt solution with one part of the 
40 volume strength formalin is also recommended. 

Another method of preserving the natural color of specimens is as 
follows : l One-half of the capacity of a metal box is filled with a con- 
centrated solution of ammonium sulphate, an excess of the crystals 
being left at the bottom of the tank. Above the crystals is arranged 
a grating upon which the specimens to be acted upon are placed. At 
the bottom of the box is a small opening through which carbon dioxid 
or ordinary illuminating gas is constantly passed, thus permitting it 
to bubble up through the fluid in the box. Another tube at the top 
of the box is fitted with a burner so as to burn off the escaping 
illuminating gas. The specimens which remain in the solution under 
the action of the carbonic-acid gas and ammonium sulphate for from 
Forty-eight to seventy-two hours retain their color for a long while, if 
preserved in this solution. 

Injected Specimens. — Most beautiful and permanent specimens 
may be made by injecting various colored materials, such preparations 
giving especial opportunity for the study of the arterial and venous 
circulation. Thus, in the case of the liver, if the cystic duct, portal 
vein, hepatic artery, and hepatic veins be injected with four different 
colored solutions, the distribution of the various vessels may be shown 
to perfection. The microscopic study of these cases may be made later 
on. The writer has a fine specimen in his cabinet of the Trichina 
spiralis in the tongue of a cat in which the arterial circulation has 
been injected with carmin. Entwining capillaries surrounding the 
capsule arc well brought out. If a warm injecting fluid be desired, 
that of Robin may be recommended. It consists of gelatin one part 
and seven to ten parts of water, heated on a water-bath, to which two 

1 Claudius, Virclwzu's Arch., 1903, vol. clxxiv, no. 1, p. 193. 



PRESERVATION OF TISSUES 345 

per cent, of chloral hydrate is added to prevent the formation of 
mould. Any dye may be used to color this solution. 
Richardson blue may be prepared as follows : 

1. Sulphate of iron 0.62 part. 

Distilled water 30.00 parts. 

2. Red potassium ferrocyanid 2.00 parts. 

Distilled water 30.00 parts. 

Slowly mix and shake, then when an opalescent blue, add 

3. Distilled water 60.00 parts. 

Glycerin 30.00 parts. 

Alcohol 30.00 parts. 

Beale's Prussian blue may be used, and is prepared as follows : 

Glycerin 32.0 parts. 

Alcohol (50 per cent.) 32.0 parts. 

Potassium f errocyanid 0.75 part. 

Tinct. of perchlorid of iron 4.0 parts. 

Distilled water 128.0 parts. 

To decalcify bone tissue the following formula may be employed : 

Sodium chlorid 100 parts. 

Distilled water 100 parts. 

Hydrochloric acid 4 parts. 

Strong nitric acid, two parts ; chromic acid, one part ; and water, 
two hundred parts, may also be used. 

Little John 1 recommends that fresh specimens or those preserved 
by any well-known method be kept in glass jars made air-tight by 
sealing their covers with gold size and putty. The one objection to 
this method is the vapor which collects in the jars. To avoid this the 
preparations are soaked for several weeks in glycerin and water and 
afterwards placed on wool to which some formalin glycerin is added. 
Perfectly washed stomachs from cases of poisoning, such as carbolic 
acid and the corrosive acids, require no preservative whatever, and 
when thus prepared retain their natural coloring for years. 

The August 13, 1904, number of the Journal of the American 
Medical Association contains two excellent articles on the permanent 
preservation of specimens, one being by Coplin and the other by 
Herring. 

1 Journal of Pathology and Bacteriology, September, 1902, p. 369. 



CHAPTER XXIII 

BACTERIOLOGIC INVESTIGATIONS 

Although it is well known that a bacteriologic investigation is 
often a most important factor in the ultimate value of a post-mortem 
examination, such an investigation is frequently neglected because of 
the lack of facilities or of knowledge of the technic. 1 This ought not 
so to be. In the first place, the cost of equipment, as in post-mortem 
sets, is very largely determined by the conveniences, rather than by the 
necessities. The outfit mentioned on page 35 can be kept always in 
readiness, while the culture-tubes may be obtained quickly and at 
reasonable rates from the larger pharmacal manufacturing companies 
and their agencies. In the second place, the technic is not so compli- 
cated as to require more skill, except in the finer manipulations and 
diagnoses, than should be expected from an educated physician. As 
time goes on, the general practitioner who is not within easy reach of 
a pathologic laboratory or of a board of health will be more and more 
expected to be sufficiently equipped with apparatus and adequately 
trained to make cultures and even inoculations for diagnostic purposes. 
Of course, it is impossible under such circumstances to do the work 
of well-endowed laboratories and skilled bacteriologists, but the mate- 
rial may at least be studied until the time arrives for placing it in 
the hands of those devoting their especial attention to the technic of 
bacteriologic investigations. 

Collection of Material for Microscopic Observations and 
for Culture Purposes. — The important factor in the technic of a 
bacteriologic examination is that all instruments shall be scrupulously 
clean and absolutely sterile, and all sources of contamination carefully 
guarded against in every possible manner. The fluid contents and 
accumulations in abscess and serous cavities, especially meningeal, peri- 
cardial, peritoneal, and pleural, the blood, endocardial vegetations, 
ulcerated areas, and the cut surfaces of solid organs may present foci 
of bacterial invasion which are at once examined by " smear prepara- 

1 Simmonds {Virchoixfs Arch., vol. clxxv, no. 3, p. 418) believes, after making 
routine bacteriologic examinations in 1200 cases, that this procedure may sometimes 
give the only definite knowledge concerning the cause of death. 



BACTERIOLOGIC INVESTIGATIONS 347 

tions," and later on by cultures and by animal inoculations, should such 
be deemed necessary. It is important to obtain material as fresh as 
possible and in sufficient amount to permit of a thorough examination. 
Canon J states that there is danger of the migration of organisms 
within the cadaver during- the first thirty-six hours, even if it be 
properly cared for. Should an early examination be wanted, one of 
the veins of an arm may be exposed shortly after death and the blood 
thus obtained. The method so frequently employed of taking up a 
small quantity of the blood with the platinum loop often gives negative 
results, especially for culture purposes. Bulbs blown in ordinary glass 
tubing furnish one of the most satisfactory means for the securing of 
fluids during an autopsy. They may be purchased in supply houses 
or prepared as follows : A piece of thick tubing is chosen measuring 
about nine inches in length. The lower portion of the tube is drawn to 
a point and sealed. About three inches from this end, the glass is 
heated to a white heat, the tube being turned all the time and not 
allowed to bend. The open end is now blown into until a bulb about 
one inch in diameter is produced in the heated portion of the glass. 
The upper part is now closed by heat, or the opening preferably is 
filled with a small plug of cotton, and then the whole is sterilized by 
dry heat. When the bulb is wanted for use, the capillary end is broken 
off, and, after aspiration of the fluid, immediately sealed by drawing 
it to a point again. The end previously filled with cotton is also 
melted until it closes. In these hermetically sealed bulbs the material 
may be kept securely until the autopsy is completed, and then be taken 
to a. suitable place for such further examination as may be necessary. 
An ordinary 5 to 10 c.c. pipette sterilized and securely wrapped in 
cotton may also be used for this purpose. The end of the pipettte is 
placed in the fluid and suction is made through a clean piece of rubber 
tubing, or the pipette is fitted with a suction cap or bulb. Both ends 
are then sealed with the flame. By either of these methods sufficient 
material may be obtained for making differential staining tests and 
also for the inoculation of cultures or of animals. Solid material may 
be removed from the interior of an organ by means of a small spear 
made for this purpose, which has an eye in which some tissue is 
retained as the spear is withdrawn. 

Smear Preparations. — Smears which are to be examined during 



1 Deutsche Zeitschrift f. Chirurgic, 1901, vol. lxi, nos. 1 and 2, p. 93. 



. } S POST-MORTEM EXAMINATIONS 

i lie autopsy may be easily and quickly made, as there is not the same 
risk of contamination that there is in obtaining fluids and solids to be 
used for inoculation. They are prepared in the following manner: A 
number of carefully cleaned and dried cover-slips and slides are placed 
in readiness. 1 A platinum loop for fluids, or the spear-headed spatula 
for solids, is then sterilized by heating to a red glow in an alcohol flame 
or in the upper (hottest) part of a Bunsen burner. If the liquid to be 
examined is of considerable consistency, like pus, blood, and exudates, 
a drop of it is placed by the aid of the sterilized loop upon a clean 
cover-slip. The cover-slip is then dropped upon a slide one-third of its 
length from one end, and, after the drop has spread, the cover-slip is 
drawn gently by means of forceps across the remaining two-thirds of 
the slide. The slide is much easier to manipulate than two cover-slips 
prepared by drawing one over the other, is not so easily broken, and 
gives a larger field for future study. Fluids may also be spread zigzag 
upon the slide or cover-slip with the platinum loop or with a small 
pipette, the latter being preferable whenever the fluid is very thin, 
making large amounts necessary. Should the material not be suffi- 
ciently fluid to make a satisfactory smear preparation, a little distilled 
water or physiologic salt solution may be put on the glass before per- 
forming the above manipulations. If preferred, a solid organ may be 
incised with a scalpel sterilized by heat, and the cover-slip or slide 
applied directly to the freshly cut surface. The material thus collected 
may then be smeared over the glass with the platinum loop. The 
" smear" being dried with very little heat, — or, better, with none, — 
now requires only " fixing" on the glass. This is done by the routine 
method of passing it three times through a flame, with the smeared 
surface upward to avoid burning the material. If a cover-glass is used, 
the passage through the flame is made more quickly than when the 
thicker glass slide is employed. In " fixing," very great care must be 
used to avoid the application of too high a temperature, — shown by a 
brownish coloration, — which would seriously distort the bacteria, espe- 
cially if the film had not been thoroughly dried previously. By the 
heat applied in this way, the albuminous organic matter is dried or 
coagulated, and the bacteria and cellular elements are thus caused to 



1 It is well to use new cover-slips which have been cleansed in strong nitric 
acid, washed in distilled water, and kept in alcohol to which a few drops of ammonia 
have been added. When wanted for use, they should be wiped dry between the 
fingers with Chinese tissue paper or with a clean cloth. 



BACTERIOLOGIC INVESTIGATIONS 349 

adhere so firmly to the glass surface that the}- will not be washed off 
by future manipulations. Such preparations may be kept for a consid- 
erable length of time before being stained, and can be safely and easily 
protected by gumming the clean surface to a piece of card-board cut to 
the size of the ordinary glass slide, on which also may be written all 
necessary data. The cards may then be packed in a slide-box or in an 
ordinary pill-box, care being exercised that the films do not come in 
contact with anything that will be liable to rub or scratch them. 
Another way to keep two slides apart face downward is to lay short 
pieces of match-sticks across their ends and bind the slides firmly 
together with a gum elastic band placed around them lengthwise. The 
value of a negative finding in a slide from a suspected syphilitic sore 
may be considerable and is not sufficiently appreciated. 

Selection of Culture-Media. — A diagnosis made from the 
study of smear preparations must often be corroborated by cultures, 
though the previous study of the smear has frequently offered valuable 
suggestions as to the particular kind of culture-media to employ in the 
case under observation. For instance, if a diplococcus be found as the 
prevailing organism, a special medium will be necessary, as the three 
most common varieties of the diplococcus — viz., the Pneumococcus, 
the Gonococcus, and the Diplococcus intracellular is — grow poorly and 
in many cases not at all upon ordinary media. Or the microbe may be 
one that can be most easily isolated by immediate inoculation into an 
animal, as in the case of the tubercle bacterium and the Pueumococcus. 
Again, existing conditions of the organs and tissues may point to infec- 
tion by an anaerobic organism, as the gas bacterium, and in such cases 
a medium and a method suitable for anaerobic growth — namely, the 
exclusion of oxygen — must be employed. Wallis 1 drops a little of the 
melted media upon a cover-glass, places a hair suspected of containing 
the parasite upon it, puts the cover in a moist chamber, and incubates 
at the room temperature. The slide is examined in the usual manner. 

The following list, prepared chiefly according to the nomenclature 
adopted in the third German edition of Lehmann and Neumann's 
Bakteriologische Diagnostik, gives the best media for the isolation of 
the pathogenic micro-organisms most commonly found post mortem, 
those having spores being called bacilli while those which have none 
are designated bacteria. (Plate V.) 

1 Jr. Amer. Med. Assoc, August 20, 1904, p. 531. 



jco POST MORTEM EXAMINATIONS 

Bacillus anthracis. All ordinary media, especially agar. White or house mouse. 
The Bacillus subtilis is motile, while this organism is not, though very similar 
morphologically. ( Plate V, no. u>. | 

Bacillus a*dematis maligni Anaerobic culture methods. Ordinary media with the 
addition of glu< 

Bacillus tetani Anaerobic culture methods. Ordinary media with the addition of 
glucose. Spores flagellated. 

Bacterium aerogenes capsulation. Anaerobic culture methods. Ordinary media with 
addition ol glucose. ( Plate V, no. 11.) 

Bacterium colt commune. Glucose agar-agar shows gas formation, thus distinguish- 
ing it from the typhoid germ. It also contains fewer flagella than the latter. 
Agglutinates. 

Bacterium dysenteric (Shiga). Plain agar-agar. A flagellated organism not stained 
by Gram's method. Agglutinates. (Plate V, no. 8.) 

Bacterium enteritidis. The bacterium of hog cholera may produce gastric disturb- 
ances in man after eating contaminated meat. It is probably a modified form of 
the Bacterium coli. 

Bacterium influenza. Agar-agar smeared with human blood or glycerin agar. 

Bacterium paratyphoid. Grows on ordinary media. The organism stands between 
the typhoid and the colon bacterium. 

Bacterium pest is. All ordinary media. 

Bacterium pncumonice. A facultative organism growing on all ordinary media. 

Bacterium pyocyaneum. Plain agar-agar. # 

Bacterium rhinoscleromatis. Probably the same as the B. pneumonia. 

Bacterium septiccemicr hcemorrhagicus. The bacillus of chicken cholera. Should be 
studied with wine, milk, and glucose media. 

Bacterium typhi murium. The bacillus of mouse septicaemia is similar to the bac- 
terium of hog cholera and the paratyphoid. 

Bacterium typhosum. Hiss's gelatin-agar medium. Can grow on all media. Not 
stained by Gram's method. Flagellated organism. Cultures best obtained from 
Mood, spleen, and urine. Agglutinates. (Plate V, no. 7.) 

Bacterium vulgar e or proteum. Non-motile; stains with Gram. It is an anaerobic, 
r-decomposing, and agglutinative organism. 

Corynebacterium diphtheria. Blood-serum bouillon. A guinea-pig may be inocu- 
lated to see if organism is virulent, thus distinguishing it from the so-called 
p-eudodiphtheria bacillus. The Bacillus xerosis is, in all probability, this organ- 
ism. ( Plate V, no. 6.) 

Corynebacterium mallei. Optional anaerobic. Guinea-pig inoculated in the tes- 
ticle. Not stained by Gram's method. 

Corynebacterium xerosis. See Corynebacterium diphtheria?. 

coccus or Micrococcus gonorrhoea. Ascites-glycerin agar and hydrocele agar 
give fairly good results. Gonorrhceal ophthalmia may be produced in rabbits 
by inoculating the mucosa of the eye. Does not stain by Gram. (Plate V, no. 1.) 

Mycobacterium lepra. It is innocuous for animals. It is grown upon glycerin agar- 
agar with great difficulty. Acid resisting. 

Mycobacterium tuberculosis. Glycerin agar-agar is the best medium. Subcutaneous 

inoculation of guinea-pig. Probably agglutinates under proper conditions, von 

Schron has recently announced, through his assistant Galbo (Riforma medica, 

vol. x\. no. _>o, p. 800), the discovery of the phthisiogenic micro-organism 

in the caseous masses of tuberculous lungs. (Plate V, no. 4.) 



PLATE V.— BACTERIOLOGIC CHART. 

No. i. Gonococcus : smear preparation from urethral pus; stain, methylene blue. No. 2. Pneumo- 
coccus: smear preparation from sputum; Welch's acetic acid stain. No. 3. Streptococcus pyogenes : 
smear preparation from pus; stain, methylene blue. No. 4. Mycobacterium tuberculosis : smear prepa- 
ration from sputum ; stain, Ziehl's method. No. 5. Vibrio cholera : stain, carbol fuchsin. No. 6. Cory- 
nebactoium diphtheria : stain, Loffler's method; lower portion of figure shows the polar staining: of 
• s granules. No. 7. Bacterium typhosum, showing flagella : stain, van Ermenghem's method. 
Bacterium dysenteric: stain, methylene blue. No. 9. Achorion Schonleinii (favus fungus), with 
conidia and mycelia : stain, Bismarck brown. No. 10. Bacillus anthracis : smear preparation from spleen 
of a mouse; stain, gentian violet; to bring out the spores stain with Ziehl's solution. No. 11. Bacillus 
aerogenes capsulatus : smear preparation from spleen; stain, gentian violet. No. 12. Yeast cells with 
buds and ascospores, starch cell in lower right-hand corner: stain, weak Lugol's (Gram's) solution. 



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BACTERIOLOGIC INVESTIGATIONS 



351 



Micrococcus or Streptococcus intracellular^. Glycerin agar or agar smeared with 
blood gives the best results. Loffler's blood serum and potato may be used. It 
is found in the pus of the brain, cord, and ear, the nasal mucus, the sputum, 
and the urine of those affected with the disease. A large amount of the exudate 
should be used, for many of the bacteria are dead. 

Micrococcus melitcusis. Glycerin agar or potato. Grows as a bacterium. Material 
to be taken from the cervical or inguinal glands and from the lungs. Agglu- 
tinates. 

Micrococcus or Staphylococcus pyogenes aureus. Grows luxuriantly upon all media 
in general use. The M. citreus and the M. albus are but varieties of this 
genus. 

Pneumococcus or Streptococcus lanccolatus. Ascites agar and ascites-glycerin agar 
are the best media. The best method is to inoculate a mouse or rabbit sub- 
cutaneously with the rusty sputum or with pus. A mouse dies in from twelve 
to twenty-four hours, and its blood contains large numbers of the Diplococcus 
pneumonia, showing the capsule most strikingly; a rabbit dies in from two to 
five days. (Plate V, no. 2.) 

Sarcince. Best cultivated in bouillon or hay decoction, displaying fine shades of 
various colors. 

SpirocJicrta Obcrmeieri. No culture method known. Monkeys show disease after 
inoculation. 

Streptococcus pyogenes. This organism is most easily recognized by smear prepara- 
tions and grows well upon all media in common use. It produces erysipelas as 
well as pus. (Plate Y. no. 3.) 

Streptothrix actinomyecs. Grows well upon agar-agar and blood serum. Does not 
-stain with Gram's solution. 

J'ibrio cholera;. Glycerin agar. All ordinary media, especially gelatin at 22 C. 
Usually a single flagellum. Agglutinates. (Plate V, no. 5.) 

The following diseases are due to specific organisms or protozoa, 
but the etiologic factor as such, though described, has not yet been 
accepted as the cause of the affection. Acrodynia, or epidemic ery- 
thema ; anterior poliomyelitis; beriberi (possibly an arsenical neu- 
ritis); cancer; chancroid; chicken-pox; chorea; cow-pox; foot-and- 
mouth disease; measles (bacillus of Canon and of Czajkowski) ; 
miliary fever; mumps; pellagra; rabies; rheumatism; rose rash; 
scarlet fever; smallpox; syphilis (bacillus of Lustgarten and of 
van Xiessen ; baboons, apes, and monkeys show the disease upon 
inoculation); typhus; whooping-cough (Bacillus pertussis, B. minu- 
tissimus sput i, and B. tussis convulsive) ; yellow fever (Bacillus X 
and Bacillus icteroides). 

Inoculating Ccltu re-Media. — Test-tubes containing any of the 
solid or liquid media may be inoculated at the place where the autopsy 
i- performed when it is not so far from the laboratory as to endanger 
the growth of the culture by exposure to extremes of temperature. 



»c 2 POST-MORTEM EXAMINATIONS 

Sufficient heat is secured, however, by placing the tubes after inocula- 
tion, securely wrapped, in an inside coat-pocket. 

The Inst step in inoculation of the tube containing the medium is to 
" flame" the cotton plug in its mouth, for the purpose of killing any 
bacteria that may have fallen upon the cotton-wool. During inocula- 
tion the tube is held as nearly in the horizontal position as is consistent 
with safety to its contents, so as to diminish the risk of contamination 
of the medium by the falling into the tube of the bacteria from the 
air. Thus, should the tube contain a solid medium, such as blood- 
scrum or agar, it may even be inverted before inoculation. The plati- 
num wire, held in the right hand, is now sterilized by heat and cooled, 
while the cotton plug is removed from the test-tube by a corkscrew 
motion and held, inner part outward, between the index and middle 
fingers of the left hand in such a manner that it does not come in 
contact with any portion of the hand or other extraneous object. With 
the tip of the platinum wire a small portion of the substance to be 
inoculated is now placed on the surface of the medium; if this surface 
is slanting, the fluid is rubbed gently over it, or drawn in a line across 
it, thus making a " smear" and " stroke" culture, while the needle is 
thrust deep down into the medium if a " stab" culture is to be made. 
The ose is then withdrawn, the cotton plug reinserted, the needle 
sterilized, and the tube labelled and put in a warm spot until it can 
be placed in the incubator. 

If the culture is to be made from the surface of a solid organ, the 
method is the same, except that the organ is first seared with a hot 
knife and next incised with a sharp, sterile knife. Should the same 
knife be used for both purposes, it is wise, as a precautionary measure, 
to sterilize the instrument again before plunging it deep into the 
tissue. In some instances, in which many of the bacteria are dead, 
much larger amounts of the infectious material must be used for 
inoculation, and then the entire contents of a bulb or pipette may be 
introduced into a flask of bouillon or other medium. 

Cultivation of the Inoculated Tubes. — The pathogenic bac- 
teria all grow best at the temperature of the body, and so all cultures, 
except gelatin plates, are placed in an incubator during growth. If 
anaerobic methods are indicated, the tubes must be prepared for the 
exclusion of oxygen. Wright has devised a simple and satisfactory 
method, which is a modification of Buchner's two-tube method and 
.does not require any special apparatus. Its principle is based upon the 



BACTERIOLOGIC INVESTIGATIONS 353 

absorption of the oxygen in the air by pyrogallic acid and caustic 
soda, leaving an atmosphere of nitrogen. A single tube is inoculated 
in the usual way. The cotton plugs are then cut off even with the 
mouth of the tube and pushed in to the distance of three or four centi- 
metres. One cubic centimetre of a ten per cent, aqueous solution of 
pyrogallic acid is then dropped upon the cotton plug and followed by 
the same amount of a decinormal solution of caustic soda. The mouth 
of the tube is then quickly closed with a close-fitting rubber stopper 
and the culture-tube is placed in the incubator. Hirshberg * has slightly 
modified this method by mixing the pyrogallic acid and sodium nitrate 
directly with a second tube of melted agar and then pouring this over 
a deep stab culture of the inoculated agar tube. Hessee's method of 
turning sterile oil into a test-tube in which a deep stab culture has 
been inoculated is often convenient. 

Preparation of the Inoculum. — The materials used for inocu- 
lation are either the pathologic products — namely, the secretions and 
excretions and the solid tissues, which have been collected in sterile 
bulbs or pipettes from the different cavities of the body and from the 
organs — or cultures which have been obtained by the inoculation of 
these products upon culture-media. If the material is in a sterile bulb, 
break off the end of the tube with sterile forceps and expel the contents, 
by the application of heat to the bulb, — the warmth of the hand is 
usually sufficient, — into a sterile capsule (a small Petri dish with a 
ground-glass tightly-fitting cover). The injecting syringe is then 
filled from the capsule. If the fluid is too thick, it may be diluted 
with a sterile salt solution. Cultures of bacteria may be prepared in 
the same manner, and solid tissues may be emulsified in a salt solution. 

Inoculation of Animals. — The animal to be used for inoculation 
should be carefully selected from those commonly employed for experi- 
mentation with reference to its own health and to the species required, 
as indicated by the microscopic examination of the smear preparation. 
The animals most used for this purpose are the rabbit, guinea-pig, 
white mouse, rat, pigeon, and domestic fowl. These differ in their 
susceptibility to the different pathogenic bacteria infesting man, and 
negative results are sometimes seen because animals are used which 
are unsuited to the case under observation. Thus, in cases of sus- 
pected syphilis the baboon, ape, or monkey must be employed, and in 

1 Jonm. Amer. Med. Assoc, May 21, 1904, p. 1355. 
23 



J54 POST-MORTEM EXAMINATIONS 

typhoid inoculations the animal must be specially medicated so as to 
render it susceptible to the bacterium causing the disease. 

The animal should be weighed and the rectal temperature (Fig. 
I taken before inoculation, and both weight and temperature should 
be recorded at a certain time each day during the period of observation. 
The same rules apply as to asepsis in the inoculation and to avoidance 
ntamination of the inoculum as are required in a surgical opera- 
tion. The instruments, similar to those used by surgeons, are sterilized 
by boiling, owing to the difficulty of removing chemical disinfectants 
which even in traces might inhibit the growth of bacteria and so 
vitiate the experiment. An ordinary hypodermic syringe may be em- 
ployed, but one should be selected that can easily be cleansed and dis- 
infected. Koch's inoculation syringe is much used; many, however, 
prefer Roux's or some modification of it. The glass and metal por- 
tions of the syringes may be sterilized by boiling, but the washers are 
injured by frequent boiling and should be disinfected by a 5 per cent, 
solution of carbolic acid followed by careful washing in sterile water. 

The site of inoculation varies with the different animals and also 
with the different varieties of the pathogenic bacteria. The usual 
methods are the subcutaneous, the intraperitoneal, and the intravenous. 
In small animals like the mouse the last two methods are rarely used, 
although a very small dose, one or two minims, of fluid may be in- 
jected into the peritoneal cavity. Subcutaneous inoculation is com- 
monly practised in the mouse. A fold of skin is pinched up between 
the thumb and forefinger of the left hand, the hypodermic needle 
attached to the barrel of its syringe, filled with the material to be intro- 
duced, is thrust into the ridge of skin until it enters the subcutaneous 
tissue, when the fluid is slowly injected; or a piece of skin is snipped 
with a pair of sharp-pointed scissors, a probe is pushed into the sub- 
cutaneous tissue, making a small pocket, in which a portion of the 
solid inoculum is deposited. (Fig. 170.) The wound may then be 
dressed with gauze and sealed with collodion. 

The intraperitoneal inoculation is made as follows : The animal is 
held by an assistant or secured to a table. A broad area over the 
abdomen is shaven, care being taken not to injure the nipple, and the 
skin is thoroughly disinfected with a two per cent, lysol solution, which 
is washed off with alcohol. The entire thickness of the abdominal 
parietes is then pinched up into a triangular fold, the peritoneal sur- 
faces are slipped one over the other to ascertain that no coil of intestine 




M 








Fig. 171. — Method of performing peritoneal injection in a rabbit. 




FlG. 172.— Ear method of inoculating a rabbit. 




Fig. 173.— Post-mortem examination of guinea-pig, made in Ravenel pan. Near the 
four corners, but not shown in the illustration, are hooks upon which the chains are 
fastened in order to hold the animal in position. 




Fig. 174.— Post-moitem examination of a rabbit. 



BACTERIOLOGIC INVESTIGATIONS 



355 



is included in the fold, and the hypodermic needle is passed through 
the fold near its base. The fold is then released, but the syringe is 
held steady. The parietes now flatten out, leaving the needle free in 
the peritoneal cavity. The fluid is then slowly injected. (Fig. 171.) 

Intravenous inoculation is not usually practised in animals smaller 
than a rabbit. In this animal the posterior auricular vein is the one 
selected for the operation. (Fig. 172.) If a guinea-pig should be 
chosen, the jugular vein is selected and an anaesthetic is used, the A. C. 
E. mixture being preferred for general and cocaine for local anaes- 
thesia. The animal is held by an assistant or securely wrapped in a 
towel fastened with pins, the selected ear is grasped by the root and 
stretched forward towards the operator, the dorsum of the ear having 
been previously shaven and cleansed. The syringe is held as one 
holds a pen, and the needle is thrust through the skin and into the 
vein itself, being pointed in the direction of the blood stream. The 
inoculum is then slowly injected and the needle withdrawn. 

In the selection of a site for inoculation the general rule is to inject 
each variety of micro-organism into the kind of tissue which it most 
often infests in man. For instance, if the lymph-glands are the primary 
seat of invasion, the animal should be inoculated in that portion of 
its body which will afford the quickest means of carrying the infectious 
material to the lymphatics; as, in the test for glanders the bacillary 
matter is introduced into the testicle, which contains an abundance of 
these vessels and but a scant blood supply. Or, if the brain and spinal 
cord are most affected by the disease, as in rabies, an intracranial 
inoculation is preferred. Thus, the lesions found during the autopsy 
and the bacteria seen in the microscopic specimens will give a clue 
regarding the most desirable seat for the inoculation. 

Post-Mortem Examination. 1 — The post-mortem examination of 
animals dying from disease produced by experimental inoculation 
should always be made as soon as possible after their death, and not 
later than twelve hours. The animal is fastened on a board, ventral 
surface upward, by nails driven through the extremities, or by being 
tied with string to special contrivances placed at the corners. Its fur 
is then wet with a weak antiseptic liquid, such as a 2 per cent, lysol or 

1 The reader is referred to the chapter on comparative postmortems for a fuller 
description of the technic, especially in necropsies on the larger animals, as the cat, 
dog, sheep, cow, and horse. The methods in vogue for performing a bacteriologic 
postmortem are seen in Fig. 173 (guinea-pig) and Fig. 174 (rabbit). 



>;,, POST-MORTEM EXAMINATIONS 

a 5 per cent, carbolic solution, to avoid contamination, to prevent the 
flying off of hairs, and to kill any vermin which are so often present. 

The tray of the sterilizer containing the necessary instruments, 
such as scissors, scalpels, forceps, etc., and the slides, cover-slips, and 
culture-media, are placed where they may be easily reached. Then, 
with sterile forceps and scalpel, the skin of the animal in the middle 
line is incised from the top of the sternum to the pubes, or, if scissors 
be used for this purpose, the reverse order is followed. Two other 
incisions are made at right angles to this line through the axillae and 
groins. The skin is next reflected in flaps, and may be tacked to the 
board for the sake of security. The seat of inoculation is then in- 
spected, and, if any lesions are visible, the surface is seared and material 
removed for cultures and smears. The surface of the thorax is seared 
and the ribs are divided on each side of the sternum, the chest-plate 
being removed in the usual way. The pericardial sac is burnt through 
with the searing iron or incised with a scalpel. The right ventricle of 
the heart is seared, and into it the pipette is passed and filled with blood 
for the preparation of smears and inoculation of tubes. Through a 
seared tract in the middle line of the abdominal wall an incision is 
made and a specimen of the peritoneal fluid collected. A specimen of 
the urine is now saved in the same manner as described for collecting 
the blood. The spleen is excised and placed in a sterile capsule, and 
through its seared surface the spear-headed spatula is plunged and 
twisted around so that the eye is filled with material for microscopic 
and cultural purposes. This process may need to be repeated several 
times. The other organs, as the lungs, liver, kidneys, lymphatic glands, 
etc., are removed in a like manner,, and all the cavities of the body 
carefully examined. Specimens of the various tissues may be incised 
into cubes and placed in fixing fluids for future sectioning. Eyre 
suggests that a different knife or separate sterilization is needed for 
cutting each organ. After use the instruments are sterilized and disin- 
fected by boiling. The animal is wrapped in a cloth moistened with 
an antiseptic solution, as pure formalin, and cremated. Every pre- 
caution should be taken to prevent dispersion of the pathogenic bac- 
teria, — as, e.g., by the dropping of cover-glasses, which on becoming 
broken might cause infection later on. Thus, von Szekely found some 
dried-up gelatin cultures of anthrax and of malignant oedema, eighteen 
and one-half years old, to be still virulent to white mice. 



CHAPTER XXIV 



WEIGHTS AND MEASURES 



It is customary in this country and in England to give the weights 
of the organs in avoirdupois ounces, their dimensions in inches, and 
their capacity in cubic inches, though the metric system has more to 
commend it and is fast gaining favor in English-speaking countries. 
Troy weight is sometimes used and may give rise to much confusion. 

The grain is the same in both Troy and avoirdupois weights. The 
ounce avoirdupois is 437.5 grains, or 28.34 grammes. The ounce 
Troy is 480 grains, or 31.1 grammes. To convert grammes into avoir- 
dupois ounces divide by 28.34, into Troy ounces divide by 31. 1. To 
convert grammes into grains divide by 0.065. Conversely, to convert 
ounces avoirdupois into grammes multiply by 28.34; Troy ounces 
multiply by 31.1. To convert grains into grammes multiply by 0.065. 

A kilogramme equals one thousand grammes, or 2.2 pounds. A 
gramme equals one thousand milligrammes, or 15.433 grains. A 
metre equals one thousand millimetres, or 39.37 inches. A litre equals 
one thousand cubic centimetres, or 61.027 cubic inches, and is equiva- 
lent to 2.1 13 American pints or 1.76 English pints. 

An organ should be measured before it is weighed, with the excep- 
tion of the intestine, which is preferably measured after it has been 
opened in its entirety, cleansed, and weighed. Measurements should 
be made as nearly as possible under similar conditions. In the healthy 
body size is dependent upon sex, age, height, and weight of the subject, 
while in morbid states it differs according to the above conditions and 
the disease present. Some parts are preferably weighed before open- 
ing, others after opening, and still others both before and after the 
incisions are completed. Letulle gives the following table: 



Weighed before opening. 


Weighed after opening. 


Both before and after opening. 


Pineal gland. 


Alimentary tract. 


Brain. 


Pituitary body. 


Aorta. 


Liver. 


Spinal cord. 


Bladder. 


Lungs. 


Spleen. 


Glands, including salivary. 


Kidneys. 


Suprarenals. 


Heart. 


I 'terns. 


Thymus and thyroid. 


Pancreas. 





357 



358 



POST-MORTEM EXAMINATIONS 



I. Average height (European standard) : 

Adult male 172 centimetres, or 5 feet 7.7 inches. 

Adult female 160 centimetres, or 5 feet 3 inches. 

New-born male 47.4 centimetres, or 18.66 inches. 

New-born female 46.75 centimetres, or 18.4 inches. 

When a child is two years old, it is about one-half as tall as it will be 
when fully grown. The rule that a child has usually attained double 
its birth weight at the fifth month and triple at from the twelfth to the 
fourteenth month is convenient and useful in estimating an infant's 
probable age. Keating's Cyclopaedia of the Diseases of Children gives 
some valuable information on the physical conditions of childhood. 

II. Average weight (European standard) : 

Adult male 65 kilogrammes, or 143 pounds (av.). 

Adult female 55 kilogrammes, or 121 pounds. 

New-born child 3250 grammes, or 7.15 pounds. 

The American Insurance standard : 1 

A man of five feet and one inch should weigh 120 pounds. 

A man of five feet and three inches should weigh 130 pounds. 

A man of five feet and six inches should weigh 143 pounds. 

A man of five feet and nine inches should weigh 155 pounds. 

A man of five feet and eleven inches should weigh. . . . 165 pounds. 

A child may be born weighing less than a pound and live. The 
greatest recorded weight attained by man is some 1000 pounds. Gould 
and Pyle in their Anomalies and Curiosities of Medical Literature 
quote from the Medical Press and Circular an instance of a man 
born in North Carolina in 1798 who measured 7 feet 8 inches in 
height and who weighed over 1000 pounds. 

According to Orth, the mean length of a full-term, sound child is 
between fifty and fifty-one centimetres, the male being slightly longer 
than the female. The average weight of a full-term boy at birth is 
thirty-six hundred grammes, that of a girl thirty-two hundred and 
fifty grammes. For the last five lunar months of fetal life, if the 
height expressed in centimetres be divided by five, the approximate age 
of the child in lunar months will be obtained. For example, if the 
child measures thirty-five centimetres, we divide this by five, and we 
have seven, which is the number of months which the child has passed 

1 From Finlayson's Clinical Manual. 



WEIGHTS AND MEASURES 



359 



in itt era. The fetal age of the child in the first five months about 
equals the square root of the height expressed in centimetres. For 
example, if the height is sixteen centimetres, the child is four lunar 
months old. In terms of the English system the length of the 
new-born child is twenty inches, which divided by two will give 
approximately the number of lunar months that the child has passed 
/"// utero. 

Embryos l about one millimetre long are about twelve days old ; 
2.5 mm., fourteen days old; 4.5 mm., nineteen days old; seven mm., 
twenty-six days old; 11.5 mm., thirty-four days old; seventeen mm., 
forty-one days old. For all embryos from one to one hundred mm. 
long, multiply the length of the embryo from the vertex to the breech 
in millimetres by one hundred and extract the square root; the result 
will be the age in days. For embryos from one hundred to two hun- 
dred millimetres long, measure from vertex to breech; this length in 
millimetres will equal the age expressed in days. 

Lambinon 2 gives the following figures, obtained at the Liege Ma- 
ternity, as to the weight of the placenta in cases of miscarriage. The 
average weight of the placenta at six weeks was 20 grammes (about 5 
drachms) ; at ninety days, 6j grammes (17% drachms) ; at one hun- 
dred and twenty days, 11 1 grammes (28% drachms) ; at one hundred 
and sixty-five days. 262 grammes (67% drachms) ; and at two hundred 
and thirty-five days. 330 grammes (85 1 / 4 drachms). The average 
weight of the placenta at term is a little over a pound (500 grammes). 
Under similar conditions to the above the length of the umbilical cord 
averages one-half a metre. Its weight is 27 grammes. 

According to Hirst, the following are the dimensions of a full- 
term, healthy child: Length of hair, from two to three centimetres; 
anterior fontanel, from two to two and one-half centimetres ; occipito- 
frontal circumference, thirty-four and one-half centimetres; occipito- 
frontal diameter, eleven and three- fourths centimetres; occipitomental 
diameter, thirteen and one-half centimetres; bisacromial diameter, 
twelve centimetres; intertrochanteric diameter, nine or ten centi- 
metres. The width of the large fontanel may be stated to be from 
two to two and a half centimetres. 

1 Mall, Bull. Johns Hopkins Hosp., vol. xiv, no. 143, February, 1903, P- 29; 
attracted in Medicine, vol. ix, no. 3. 19/33. p. 240. 

2 Dc la determination dc Vage du f<ctus d'apr'cs Ic poids du placenta dans les cas 
dc fausse couche. Paris, 1898. 



POST-MORTEM EXAMINATIONS 

fohn C, Cook ' cites Fehling as giving the percentage of water in 
a very young Foetus as 97.5 per cent.; after birth, 74.7. In the adult 
it is 58.5 per cent. ECatz - has made sonic interesting chemical analyses 
of muscle taken from man and from the lower animals. The younger 
the animal the more water will it contain, the cardiac muscle con- 
taining the least water. I [orse-flesh can be told by its high iodin index 
and specific blood-test. 

1 1 1. Table oi approximate weight of the internal organs: 



Adult, New-born, 

grammes, grammes. 

Brain 1397 385 

1 1 cart 304 24 

Lungs 1 172 58 3 

Liver 1612 118 

Pancreas 201 11. 1 

Right kidney 141 

Left kidney 150 



Adult, New-born, 

grammes. grammes. 

Roth kidneys 299 23.6 

Testicles 48 0.8 

Ovary 0.5 

Muscles 29,880 625 

Skeleton 11,560 445 

Thymus 8.5 

Spleen 8.5 



IV. The body weight by percentage : 



Heart 0.52 

Lungs 2.01 

Stomach and alimen- 
tary canal 2.34 

Pancreas 0.346 



per cent. per cent. 



O.41 



Adult, New-born, 
percent. percent. 



0.89 Liver 2.77 

2.16 Brain 2.37 

Thymus gland 0.0086 

2.53 Skeleton 15.35 



Muscles 43-Q9 



4-39 
14.34 

o.54 
16.70 
23.40 



In measuring an organ its length, breadth, and thickness may 
often be more quickly and accurately ascertained by thrusting the steel 
rule through it than in any other manner. 



THE SKULL AND ITS CONTENTS. 
Shape. — Even in members of the same race the form of the skull 
is subject to marked variations, and these are still greater when indi- 
viduals of different races are compared. The characteristic measure- 
ments of the cranium are its length, height, and breadth. The cephalic 
index is the ratio of its length (taken as one hundred units) to its 
breadth. The altitudinal index is the ratio of its length to its height. 



' Jr. .Imcr. Med. Assoc, June 6, 1903, p. 1548. 
'Arch. ges. Physiol., 1896, vol. lxiii, no. 1, p. 1. 
1 The right heing about 5 grammes the heavier. 



WEIGHTS AND MEASURES 361 

The accepted horizontal plane is that passing through the upper edges 
of the external auditory meatus and the lower orbital margin. 

According to the variations of the cephalic index, we distinguish 
the dolichocephalic (index less than 75) and the brachy cephalic (index 
more than 80) types. Intermediate forms are called mesocephalic. 
If the ratio of the breadth to the height is less than 70, the skull is 
platycephalic; if between 70 and 75, orthocephalic; if above 75, liypsi- 
ceplialic. The character of the facial profile is indicated by the facial 
angle of Camper, — namely, the angle between a line on the level of 
the external auditory meatus and the floor of the nasal cavity and a 
line touching the middle of the forehead and the anterior portion of 
the alveolar process of the superior maxilla. If this angle be 80 de- 
grees or more, the skull is called orthognathous; if it is between 80 
degrees and 65 degrees, prognathous (Gegenbaur). 

Pathologic types of skull are due in part to premature synostosis. 
Among them we distinguish the hydrocephalic type (from dropsy of 
the ventricles), the cephalonic (or big head), the microcephalic (or 
small head), the dolichocephalic (or long head), the sphenocephaly 
(or wedge-shaped head, due to compensatory development of the ante- 
rior fontanel), the leptocephalic (or narrow head), the clinocephalic 
(or saddle-shaped head), the trigonocephaly (or triangular head, due 
to narrowing of the frontal bone from fetal synostosis of the frontal 
suture), the brachycephalic (or short head), the pachycephalic (in 
which the bones of the cranium are thickened), the oxycephalic (or 
pointed head), the platycephalic (or flat head)', the trocho cephalic 
(or round head), and the plagio cephalic (or unsymmetrical oblique 
head). 1 

Weight. — The maximum weight of the adult male encephalon is 
about 2222 grammes, or 74 ounces, and the minimum is about 960 
grammes, or 34 ounces. The average is about 1400 grammes, or 49.5 
ounces. The maximum weight of the adult female encephalon is about 
1585 grammes, or 56 ounces, and the minimum is 880 grammes, or 31 
ounces. The average is from 1230 to 1245 grammes, or from 43^ 
to 44 ounces. Thus it will be seen that the adult male brain is on an 
average four or five ounces, or about nine per cent., heavier than that 
of the female. See also American Medicine, May 17, 1902, p. 830. 



1 Ziegler's Text-Book of Special Pathological Anatomy, English Translation by 
MacAlister and Cattell. vol. i. pp. 206, 207. 



102 



POST-MORTEM EXAMINATIONS 



Table showing in grammes the mean weights of the brain at dif- 
ferent ages in the two sexes: 

Male. Female. 

Children stillborn at term 393 347 

Children born alive at term 33° 283 

Under three months of age 493 45 1 

From three to six months 602 560 

From six to twelve months 77 6 7 2 7 

From one to two years 94 1 8 43 

From two to four years i>Q95 99° 

From four to seven years 1,138 i,i35 

From seven to fourteen years i,3 01 I , I 54 

From fourteen to twenty years i»374 1,244 

From twenty to thirty years i,333 i, 2 37 

From thirty to forty years i,3 6 4 1,220 

From forty to fifty years i,35 x 1,212 

From fifty to sixty years 1,343 I , 22 ° 

From sixty to seventy years T ,3 T 3 1,208 

From seventy to eighty years 1,288 1,168 

Over eighty years 1,283 1,125 

By the above table it appears that the brain is relatively heavier 
between fourteen and twenty years of age than at any other period; 
but according to Broca, and also Peacock, the maximum is attained 
between the ages of twenty-five and thirty-five. 

Orth quotes Meynert, whose results were obtained from the inves- 
tigation of 157 cases in the Vienna insane asylum. He gives the mean 
weight of the brain, in men between the ages of twenty and sixty-nine 
years, as 1296 grammes; in women, 11 69 grammes. He says the 
maximal weight is attained during the fourth decade in men and the 
fifth decade in women. The average weight of the cerebrum is 1018 
grammes in men and 917 grammes in women; of the brain stem, 143 
grammes in men and 129 grammes in women; of the cerebellum, 135 
grammes in men and 123 grammes in women. Weisbach found that 
in sane German- Austrians the brain weighed 13 14.5 grammes in men 
and 1 179.52 grammes in women, while the cerebrum weighed 1154.97 
grammes in men and 1038.90 grammes in women, the cerebellum 
1 4 j. j grammes in men and 125.56 grammes in women, and the pons 
17.33 grammes in men and 15.06 grammes in women. Bischoff found 
the weight of the pia and arachnoid to be from 25 to 40 grammes. 
Nauwerck quotes Vierordt, who found the mean weight of the brain 
in men within the ages of twenty and eighty years to be 1359 grammes, 
in women 1 j^^ grammes. The brain of the recently deceased Japanese 



WEIGHTS AND MEASURES 363 

anatomist Taguchi weighed 1920 grammes, the body weight being 49 
kilos. TourgeniefTs brain weighed 2120 grammes, while that of 
Rustan reached 2222 grammes (74 ounces). 

The weight of the encephalon relative to that of the body is subject 
to great variation, but may approximately be put down as 1 to 36.5 in 
the adult male and 1 to 35.2 or 1 to 36.46 in the female. These figures 
are based on observations upon persons dying from more or less pro- 
longed disease, but in the cases of a few individuals who died suddenly 
from disease or accident the average ratio was found to be 1 to 41. 
The proportion to body weight is much greater at birth than at any 
other period of extra-uterine life, being about 1 to 5.85 in the male 
and 1 to 6.5 in the female. 

The weight of the human cerebrum also bears a somewhat definite 
relation to the stature of the individual. The weight in ounces may be 
obtained for a male by dividing the height in inches by 1.6, and for 
a female by multiplying the quotient thus obtained by fy. The weight 
in grammes may be obtained by multiplying the height in centimetres 
by 7 for a male, and the product again by ff for a female. Thus, 



Weight in ounces of the mean cerebrum . 



height in inches 

~~ E6 

„. • u . • c * 1 i -, u height in inches 30 

W eight in ounces of the mean female cerebrum = — X — 

1.6 /x 3i 

Weight in grammes of the mean male cerebrum . . = height in centimetres X 7 
Weight in grammes of the mean female cerebrum = height in centimetres X 7 X 



These proportions are slightly deficient for the higher and ex- 
cessive for the lower statures. 

Dimensions. — The mean cubic capacity of the male cranium is 
1450 cubic centimetres; that of the female is 1300 cubic centimetres 
(YVelcker). The length of the male brain is from 160 to 170 milli- 
metres, or from 6| to 6^ inches, and that of the female brain is from 
150 to 160 millimetres, or from 6 to 6| inches. The greatest trans- 
verse diameter is 140 millimetres, or 5! inches, and the greatest ver- 
tical diameter is 125 millimetres, or 5 inches. The volume is about 
1330 cubic centimetres, or 81 cubic inches. 

The specific gravity of the brain is from 1035 to 1040. 

Pituitary gland, length, .008; breadth, .012; thickness, .065; 
weight, 5 grammes ( Zander J. 

Pineal gland measures .010 X -005 X -005 (Charpy) and weighs 
0.20 gramme (Engel). 



> n} POST-MOR I'KM l-:XAMINATIONS 

The length of the spinal cord in the adult is 0.448 metre and its 
weight, deprived of its nerves, 27 to 30 grammes. The transverse 
diameter of the cervical enlargement, 0.013; of the dorsal, 0.01 ; and 
of the lumbar, 0.012. The anteroposterior diameter of the cervical 
enlargement, 0.009; ol lnc dorsal, 0.008; of the lumbar, 0.009. 

THE HEART. 

Weight. — The mean weight of the heart in the adult male is about 
310 grammes, or 11 ounces; its proportion to the body weight is 1 to 
[69. That of the adult female is about 255 grammes, or 9 ounces; 
proportion to body weight, 1 to 149. According to Krause, the pro- 
portion of the heart weight to the body weight is as 1 to 169 in men 
and as 1 to 162 in women. The increase in weight from the fifteenth 
to the seventieth year is about 60 grammes in the male and 25 grammes 
in the female. 

The weight of the heart increases with the body weight, but in 
a gradually decreasing ratio, until the seventieth year, when it begins 
to diminish. At birth it is about 24 grammes; proportion, 1 to 130 
(Quain). 

Dimensions. — The determination of the exact measurements of 
the heart is most difficult, as the muscular fibres contract and expand 
under such diverse circumstances and the positions of the parts are 
so different. Constantin Paul has called attention to the fixed manner 
in which the inferior vena cavity enters into the heart on a line with 
the tip of the right auricular appendix. The heart is generally of about 
the same size as the right fist of the cadaver. Its extreme length is 
about 125 millimetres, or 5 inches; width, 87 millimetres, or 3 inches; 
thickness, 62 millimetres, or 2 l / 2 inches, slightly less in the female than 
in the male. The thickness of the wall of the right ventricle is from 
2 to 5 millimetres, or T V to % of an inch; of the left ventricle, from 
7 to 12 millimetres, or % to f of an inch; ventricular septum, 15 
millimetres. Pathologically these measurements may be increased 
threefold or more. 

Nauwerck and Orth quote Bizot as follows: The weight of the 
heart is 300 grammes in men and 250 grammes in women. The length 
in men is from 85 to 90 millimetres, in women from 80 to 85 milli- 
metres; the breadth in men is from 92 to 105 millimetres, in women 
from 85 to 92 millimetres; the thickness in men is from 35 to 36 milli- 
metres, in women from 30 to 35 millimetres. The thickness of the 



WEIGHTS AND MEASURES 365 

right ventricle without the trabecules is from 2 to 3 millimetres in men 
and slightly less in women; the left ventricle is from 7 to 10 milli- 
metres thick. The heart of the elephant Jumbo is reported to weigh 
36 1 2 pounds after having soaked several years in alcohol. 

The dimensions of the orifices of the heart are shown in the fol- 
lowing tabular statement. 

/->-;.;,,- i->:„ „*„- Circumference. Area. 

Orifices. Diameter. Ma , e Fema i e . Male Female. 

Aortic 24 to 25 mm., or Si mm. 76 mm. 530 sq. mm. 452 sq. mm. 

0.9 to 1 in. 
Mitral 30 to 35 mm., or 103 mm. 101 mm. 855 sq. mm. 804 sq. mm. 

1.2 to 1.4 in. 
Pulmonary .... 27 to 30 mm., or 91 mm. 89 mm. 660 sq. mm. 615 sq. mm. 

1.1 to 1.2 in. 
Tricuspid 37 to 45 mm., or 122 mm. 115 mm. 1194 sq. mm. 1017 sq. mm. 

1.5 to i.S in. 

Bizot's figures for the circumference are, as a rule, slightly less. 

Volume. — In the new-born this is about 22 cubic centimetres, 
which is increased to 250 centimetres at twenty years and about 280 
centimetres at fifty years, after which it gradually decreases. Up to 
the age of puberty it is about the same in both sexes, but after that it 
is from twenty-five to thirty centimetres larger in the male. Because 
of obvious difficulties, these figures can only be regarded as approxi- 
mate. 

Thickness of the aorta, Ij4 to 2 millimetres (Orth). Circum- 
ference of the thoracic aorta, 4 to 6 centimetres; of the abdominal 
aorta, 35 to 45 centimetres; weight, 35 to 45 grammes. The trans- 
verse sections of the aorta will about admit the thumb. The length 
of the inferior vena cava is 0.22 to 0.25 metre; of the superior, .06 
to .08: of the great azygos, .20 to .25; and of the portal veins, .05 
to .12. 

The length of the thoracic duct is .30 to .34 metre. 

THE LUNGS. 
Weight. — Obviously the lungs are subject to great variation in 
weight, depending upon the amount of blood or other liquid and of 
air in their cavities. Their combined weight ranges from 850 to 1370 
grammes, or from 30 to 48 ounces, the average being from 1020 to 
1 190 grammes, or from 36 to 42 ounces (1300 grammes in the male 
and 1023 grammes in the female. — Krause). The right is generally 
2 ounces heavier than the left. The weight of the right lung is from 



»56 POST-MOF it.m examinations 

rammes; that of the left lung, from 325 to 480 grammes 
1 Schmaus quoted by Nauwerck). Sappey's figures are more by 100 
grammes. The lungs are absolutely heavier in the male and also 
appear to be heavier in proportion to the body weight. 

Dimensions. — The extreme length of the right lung in the male 
is 271 millimetres, or 10 J inches, and that of the left is 298 milli- 
metres, or 1 2 inches; and in the female, 216 millimetres, or 8f inches, 
and 230 millimetres, or 9-5 inches, respectively. The extreme outer 
and posterior diameters in the male are, of the right, 203 millimetres, 

8 s inches, and of the left, 176 millimetres, or 7 inches; and in 
the female. 176 millimetres, or 7 inches, and 162 millimetres, or 6^2 
inches, respectively. The transverse diameter at the base is, in the 
male. 135 millimetres, or 5! inches, for the right, and 129 milli- 
metres, or 5 1 ,; inches, for the left. In the female the measurements 
j j millimetres, or 4% inches, and 108 millimetres, or 4^ inches, 
respectively. (Krause, quoted by Vierordt.) 

The specific gravity of the healthy adult lung varies from 345 to 
740. When fully distended with air it is about 126, while that of the 
lung tissue itself, entirely deprived of air, is about 1056. 

SALIVARY GLANDS. 

Parotid weighs 25 to 30 grammes; submaxillary, 8 grammes; and 
sublingual, 2 to 3 grammes. 

MEASUREMENTS OF THE ALIMENTARY TRACT. 

CEsophagus, length, 0.26 metre; breadth, 0.045; thickness, 0.009; 
weight, 40 grammes. 

Stomach (empty), superior border, 0.09 metre; thickness, 0.007; 

.:'it. 145 grammes. 

Small intestine, length, 6 to 8 metres ; weight, 640 to 730 grammes; 
duodenum, length, 0.26 metre. Large intestine, length, 1.40 to 1.70 
metres; caecum, 0.08 to 0.1 metre. 

Vermiform appendix, 0.04 to 0.08 metre; weight, 460 to 500 
grammes. 

THE LIVER. 
Weight. — The liver weighs from 50 to 60 ounces in males, a little 
in females. 3 Its mean weight is 1600 grammes, — from a minimum 

1 The weight varies, whether before or after letting out the blood, in certain 
cardii 1 '1 in enlargement from malaria. 



WEIGHTS AND MEASURES 367 

of 1247 grammes to a maximum of 1981 grammes, — according" to 
Vierordt, quoted by Nauwerck. In a four-months foetus it is about 
one-tenth of the body weight ; at birth it is one-twentieth ; in the adult 
male it is one- fortieth ; in the adult female it is one-thirty-sixth. 

Dimensions. — (Quain.) The transverse diameter is from 150 to 
200 millimetres, or 6 to 8 inches; vertical diameter, from 125 to 175 
millimetres, or 5 to 7 inches; and anteroposterior, from 100 to 150 
millimetres, or 4 to 6 inches. 

(Morris.) Transverse, from 175 to 250 millimetres, or 7 to 10 
inches; vertical, from 150 to 175 millimetres, or 6 to 7 inches; and 
anteroposterior, from 75 to 150 millimetres, or 3 to 6 inches. 

(Gray.) Transverse, from 250 to 300 millimetres, or 10 to 12 
inches; vertical, 75 millimetres, or 3 inches; and anteroposterior, 
from 150 to 175 millimetres, or 6 to 7 inches. 

Right lobe, from 18 to 20 centimetres. Left lobe, from 8 to 10 
centimetres. Longitudinal diameter : right, from 20 to 22 centi- 
metres; left, 15 or 16 centimetres. 

According to Orth, the transverse diameter is from 25 to 30 centi- 
metres, that of the right lobe being from 18 to 20 centimetres and that 
of the left from 8 to 10 centimetres. The anteroposterior diameter 
averages from 19 to 21 centimetres, — from 20 to 22 centimetres for 
the right lobe and 15 or 16 centimetres for the left. The greatest ver- 
tical diameter is from 6 to 9 centimetres. The hepatic lobules vary in 
size from 1 to 3 millimetres. 

Volume, — This varies from 1475 to 1638 cubic centimetres, or 
from 90 to 100 cubic inches. The mean volume is 1574 cubic centi- 
metres. 

The specific gravity is between 1050 and 1060, which in fatty de- 
generation may be reduced to 1030 or even less. 

Supernumerary livers may weigh an ounce or more. 

Gall-bladder: length, 0.08 to 0.17 metre; diameter at base, 0.03; 
thickness of wall, 1 to 2 millimetres. 

THE KIDNEYS. 

W eight. — Each kidney weighs from about 127.5 to l 7° grammes, 
or 4>2 to 6 ounces, in the male, and from 113 to 156 grammes, 4 to 
$y 2 ounces, in the female. The left kidney is usually a little heavier 
than the right, — from 5 to 7 grammes heavier, according to Orth, who 
states that one kidney weighs about 150 grammes, while both kidneys 



POST MORTEM EXAMINATIONS 

after the removal of the connective tissue of the hilum weigh 320 
grammes in men and 293 grammes in women. At the end of the first 
\ ear the kidneys together weigh 62 grammes. The ratio of the weight 
of the kidneys to the body weight is as 1 to 200. The mean proportion 
of the weight of the heart to the weight of the kidneys between the 

- of twenty and thirty-five years is as 1 to 1. 1 (Thoma). 

Dimensions. — Length about 10 centimetres, 2]/z inches; breadth, 
5 to (> centimetres; and thickness, from 3 to 3.5 centimetres, i l /\. to 1^2 
inches; or in the proportions of about 1 to ^ to %. The left kidney 
is usually a little longer and narrower than the right. 

Specific Gravity. — About 1050. 

The following points serve to distinguish between the right and left 
kidneys. 

Right Kidney. Left Kidney. 

Impression from liver. No impression from spleen. 

Shorter and broader. Longer and narrower. 

From five to seven grammes lighter. About five to seven grammes heavier. 

The spermatic or ovarian vein empties The spermatic or ovarian vein empties 
into the inferior vena cava. into the renal vein. 

The right kidney is usually situated a little lower down in the body 
than its fellow, owing to the liver being larger than the spleen. 

In both kidneys the posterior surface is the flatter, the external 
border is convex, the internal border concave, and the upper portion is 
more expanded than the lower. At the hilum the attachment of ves- 
sels and ureter is, from above downward, the body being in the erect 
posture, artery, vein, ureter ( AVU) ; and from before backward, vein, 
artery, ureter (VAU). Place the organ on the table, with its pos- 
terior surface down, the lower extremity (the ureter pointing down- 
ward) being towards the observer. The ureter is then behind and 
below the other vessels, and the hilum will be directed towards the 
side of the operator to which the kidney belongs, — i.e., towards the 
left hand if it is the left kidney, and towards the right hand if it is 
the right kidney. The ureters are from 27 to 30 centimetres long, 
with a circumference of 1 centimetre. Bladder: height, empty, 4 cen- 
timetres; transverse diameter, 6 to 7 centimetres; weight, 30 to 60 
grammes. Urethra: male, 15 to 17 centimetres; female, 3.5 centi- 
metre^, with a diameter of 7 to 10 millimetres. 



WEIGHTS AND MEASURES 



369 



ADRENALS (SUPRARENAL BODIES). 

Weight. — Each suprarenal weighs about 5 grammes, or 4 drachms, 
the left being slightly the heavier. They are nearly as large at birth as 
in adult life. Orth gives the weight in adults as from 4.8 to 7.3 
grammes; Sappey, 7 grammes; Testut and Poirier, 6 to 7 grammes. 

Dimensions. — Vertical length is from 30 to 50 millimetres, or i*4 
to 2 inches; breadth, from side to side, about 30 millimetres, ij4 
inches; thickness, from 5 to 6 millimetres, -J- to J4 inch. Nauwerck 
states that the mean diameters are from 4 to 5 centimetres, 2.5 to 3.5 
centimetres, and 0.5 centimetre. 

THE SPLEEN. 

Weight. — This organ varies within wide limits in both size and 
weight. Ordinarily its weight is between 100 and 300 grammes, or 
-$y 2 and 10 ounces, with the average at about 170 grammes, or 6 
ounces. In intermittent and some other fevers it may weigh 18 or 20 
pounds. Orth states that the normal weight varies between 150 and 
250 grammes. Its weight in proportion to the body weight is at birth 
about 1 to 350; in the adult, 1 to from 320 to 400; and in old age, 
1 to 700. 

Dimensions. — Generally the spleen is from 125 to 150 millimetres, 
or 5 to 6 inches, in length; from 75 to 90 millimetres, or 3 to 3J/2 
inches, in breadth; and from 25 to 40 millimetres, or 1 to 1/2 inches, 
in thickness. According to Orth, the length is from 12 to 14 centi- 
metres, the breadth 8 or 9 centimetres, and the thickness 3 or 4 centi- 
metres. 

Volume. — This does not usually exceed from 200 to 300 cubic 
centimetres, or 12 to 18 cubic inches. Orth gives 221.5 cubic centi- 
metres as the mean volume. 

THE PANCREAS. 

Weight. — The weight is very variable, — from 30 to 100 grammes, 
or 2 to 33^ ounces, and may even be 170 grammes, or 6 ounces; in 
adults, from 90 to 120 grammes (Orth). Testut gives that of the 
male, 70 grammes ; of the female, 66 grammes. 

Dimensions. — From 120 to 150 millimetres, or 5 to 6 inches, in 
length; and from 12 to 25 millimetres, or / 2 to 1 inch, in thickness. 
Length 23 centimetres, breadth 4.5 centimetres, thickness 3.8 centi- 
metres (Orth). 

Specific Gravity. — 1046. 



POST-MORTEM EXAMINATIONS 

THE THYMUS GLAND. 

Weight. — At birth this gland weighs about half an ounce. In 
twenty adult cases it was found to average 5 grammes (Quain). 
Friedleben says that the thymus weighs at birth 14 grammes and at 
nine months of age 20 grammes. Up to the second year it weighs a 
little more than 26 grammes, and from the third to the fourteenth year 
a little less than this. 

Dimensions. — At birth the length is about 60 millimetres, or 2 

inches; width. 37 millimetres, or i l / 2 inches; and thickness, from 6 

N millimetres, or r 4 to \ 3 of an inch. From birth to the second 

month the leng-th is 5.2 centimetres; from the ninth month to the 

rid year. 6.96 centimetres, and from the third to the fourteenth 
year, 8.44 centimetres. The breadth across the middle is from 2.7 to 
4.1 centimetres: above and below, from 0.7 to 0.9 centimetre (Fried- 
leben ) . 

THE THYROID GLAND. 

Weight. — From 28 to 56 grammes, or 1 to 2 ounces, being larger 
in the female. Orth gives the weight as from 30 to 60 grammes. 

Dimensions. — Each lateral lobe is about 50 millimetres, or 2 inches, 
in length; from 18 to 30 millimetres, or J4 inch to ij4 inches, in 
breadth; and from 18 to 25 millimetres, or ^4 to 1 inch, in thickness. 
The right lobe is usually the larger. The isthmus is nearly 12 milli- 
metres, or y 2 inch, in breadth, and from 6 to 18 millimetres, or % to 
Ya inch, in depth. According to Orth, each lateral lobe is from 5 to 7 
centimetres long, from 3 to 4 centimetres broad, and from 1.5 to 2.5 
centimetres thick. 

THE TESTES. 

Weight. — Each testicle with its epididymis weighs from 18 to 25 
grammes, or 6 to 8 drachms, the left being slightly the heavier. Orth 
gives 18 to 26 grammes as the weight; Nauwerck says the testicle and 
epididymis weigh from 15 to 24.5 grammes. 

Dimensions. — Length, about 37 millimetres, or i J / 2 inches; 
breadth, anteroposterior, 30 millimetres, or i*4 inches; thickness, 
from side to side, 24 millimetres, or 1 inch. 

THE OVARIES. 

Weight. — From 4 to 8 grammes, or 1 to 2 drachms. Orth gives 
7 for the weight, and Xauwerck quotes Puech, who puts the mean 
weight at 7.0 (from 5 to 10) grammes. 



WEIGHTS AND MEASURES 



371 



Dimensions. — Length, usually about 37 millimetres, or iJ/£ inches; 
breadth. 18 millimetres, or Y\ inch; thickness, 12 millimetres, or Yz 
inch. The right is usually a little larger than the left. According to 
Orth, the ovary is from 2.5 to 5 centimetres long, from 2 to 3 centi- 
metres broad, and from 7 to 12 millimetres thick. Nauwerck gives 
the following dimensions, quoted from Puech. 

Length, maidens from 4. 1 to 5.2 centimetres. 

Length, women from 2.7 to 4.1 centimetres. 

Breadth, maidens from 2.0 to 2.7 centimetres. 

Breadth, women from 1.4 to 1.6 centimetres. 

Thickness, maidens from 1.0 to 1. 1 centimetres. 

Thickness, women from 0.7 to 0.9 centimetre. 

THE UTERUS AND BREASTS. 

Weight. — Generally from 28 to 42 grammes, or 1 to ij^ ounces. 
Orth quotes Huschke, who gives from 33 to 41 grammes as the weight 
of the uterus in virgins and 105 to 120 grammes as the weight in 
multiparas. Nauwerck gives 33 to 41 grammes as the weight in vir- 
gins, and 102 to 117 grammes as the weight in multiparas. 

Dimensions. — Length, about 75 millimetres, or 3 inches; breadth, 
50 millimetres, or 2 inches; thickness, nearly 25 millimetres, or 1 inch. 
The virgin uterus is from 5.5 to 8 centimetres long, from 3.5 to 4 
centimetres broad, and from 2 to 2.5 centimetres thick; in multiparas 
the womb is from 9 to 9.5 centimetres long, from 5.5 to 6 centimetres 
broad, and from 3 to 3.5 centimetres thick. The walls of the virgin 
uterus are from 1 to 1.5 centimetres thick; of the cervix, from 0.7 to 
0.8 centimetre thick. In multiparas the uterine walls may be as thick 
as 2 centimetres, and the cervix is from 0.8 to 0.9 centimetre thick. 
(Orth.) 

The length of the virgin or nulliparous uterus, from the fundus 
to the external os, is from 7.8 to 8.1 centimetres and the breadth of 
the fundus is from 3.4 to 4.5 centimetres; the thickness below the 
fundus is from 1.8 to 2.7 centimetres; the length of the cervix is from 
2.9 to 3.4 centimetres; the breadth of the cervix is 2.5 centimetres; 
the thickness of the cervix is from 1.6 to 2 centimetres. In multiparas 
the length of the uterus is from 8.7 to 9.4 centimetres, the breadth 
5.4 to 6.1, and the thickness 3.2 to 3.6 centimetres. The length of the 
uterine cavity in virgins is 5.2 centimetres, after the menopause 5.6 
centimetres: in multiparas 5.7 centimetres, after the menopause 6.2 
centimetres. ( Nauwerck.) 



POST-MOK IT.M l.XAMINATIONS 

Breasts at birth, 0.30 to 0.60 gramme; of adult, 150 to 200 
unios; during lactation, 400 to 900 grammes. 

THE PROSTATE AND SEMINAL VESICLES. 

Weight — Average, from 18 to 20 grammes, or 4^ to 4j4 
drachms. Orth gives 17 to 18.5 grammes as the weight; and Nau- 
werck quotes Krause and Bischoff, who give 19 to 20.5 grammes as 
the weight. 

Dimensions. — Transverse diameter, about 37 millimetres, or i 1 /* 
inches; vertical,. 30 millimetres, or 1% inches; anteroposterior, 18 
millimetres, or % inch. These measurements are subject to great 
variation, according to the fulness of the rectum and bladder. Ac- 
cording to Orth, the prostate measures from 32 to 45 millimetres in 
its transverse diameter, 14 to 22 millimetres in thickness,, and 25 to 35 
millimetres from apex to base. Nauwerck gives the following dimen- 
sions : Transverse diameter (breadth), from 3.2 to 4.7 centimetres 
(mean, 4.5 centimetres) ; sagittal diameter (thickness), from 1.4 to 
2.3 centimetres (mean, 2 centimetres) ; from apex to base (height), 
fioni 2.3 to 3.4 (mean, 2.7 centimetres). 

The seminal vesicles measure 4.2 by 17 by 0.9 centimetres. 



CHAPTER XXV 

COMPARATIVE POSTMORTEMS * 

The great number, importance, and variety of diseases which 
human beings may contract from the lower animals are more and more 
coming to be recognized. Our domestic animals suffer from nearly 
all the contagious maladies found in man, and impart to him various 
disorders from which he would otherwise be exempt, such as glanders, 
actinomycosis, anthrax, hydrophobia, foot-and-mouth disease, echino- 
coccus cysts, trypanosomatosis, etc. The rat disseminates bubonic 
plague, the mosquito malaria, yellow fever, and dengue, and the pig 
trichinosis, and were it not for the rat, the mosquito, and the pig these 
diseases would probably cease to exist. 

The skin, extremities, joints, excessive functionation of the mam- 
mary gland, and the frequency of parasitic lesions in the muscular 
tissue are so often subject to pathological conditions that they present 
a rich field in post-mortem examinations of lower animals. Malfor- 
mations are also quite common. 

There has recently taken place an interesting discussion as to Koch's 
statements that human tuberculosis differs from bovine and cannot be 
transmitted to cattle, and that man does not, except in the rarest in- 
stances, contract tuberculosis from the cow. Both sides admit, how- 
ever, that there is a great difference between the virulence of various 
forms of the tubercle bacilli. As we go to press, Koch promises the 
publication of experiments carried on while he was in Africa which 
will completely prove his original assertions, while the British Royal 
Commission report that they have reached positive conclusions which 
refute the claims of the celebrated German bacteriologist. In Switzer- 
land and in this country the writer has been struck with the freedom 
from tuberculosis of districts in which cow's milk is not used. 

Many of the suggestions made in the previous chapters apply with 
equal force to the performance of necropsies upon the lower animals. 
Such comparative examinations are of two distinct classes, — veterinary 

1 Much of the material and all the illustrations in this chapter are taken from 
Kitt's excellent work entitled Lehrbuch der pathologischen Anatomie der Haus- 
thiere, 1900. vol. ii, pp. i~54- 

373 



,-, POST-MORTEM EXAMINATIONS 

postmortems and laboratory postmortems. For laboratory study small 
animals, such as the guinea-pig, rabbit, mouse, and rat, are generally 
chosen, while in veterinary investigation the subject is usually a dog, 
a horse, a cow, or a cat. So intense is the interest now taken in com- 
parative pathology that all classes of animals come to section, even 
reptiles (especially snakes) receiving no small amount of attention. 

Instruments. — In post-mortem examinations of the large domes- 
tic animals (cow, horse, mule, etc.) the instruments used must neces- 
sarily be larger than those employed in human autopsies. The 
following is a partial list, (i) Large butcher's knife, to expose the 
thorax and abdomen and remove the skin; (2) large cleaver; (3) 
large butcher's saw, to open the thoracic and cranial cavities, expose 
the nasal septum, etc.; (4) large chisel, to remove the cord; (5) 
hammer, for the same purpose; (6) bone-forceps (costotome) ; (7) 
enterotome; (8) scissors; (9) brain-knife; (10) dissecting forceps; 
(11) large needle; (12) strong twine, etc. 

Utensils. — Buckets, pitchers, large and small enamelled plates, 
sponges, soap, towels, and disinfectants, and green soap or lysol are 
especially useful. 

Clothing. — An operator's apron may be drawn over the clothes 
or an ordinary rain-coat worn, but a special suit for operating is better. 

General Suggestions. — In many cases the necropsy must be 
made at the place where death occurred, be this in the fields, stable, 
slaughter-house, or veterinary morgue. The procedure will vary with 
the conditions and conveniences, but the end in view should be care- 
fully considered and certain general rules observed. If the animal is 
alive, the method of killing to prepare for the desired investigation 
should be one that will not injure the organs involved. In cerebral 
trouble the animal should not be killed by a blow upon the head, but 
by poison or chloroform ; in inflammatory conditions all loss of blood 
should be avoided; if the trouble is in the digestive system, no poison 
should be used ; and in pulmonary affections the animal must not be 
shot through the heart (Csokor). 

Operative Technic. — In opening the cadaver the normal position 
of the intestines should be retained as far as possible, and they should 
be carefully examined to see that they are uninjured and are suffi- 
ciently exposed. Horses, large and small ruminants, and the larger 
swine are usually placed upon the left side of the body so that the right 
side may be opened. A dorsal position may be chosen for dogs and 



COMPARATIVE POSTMORTEMS 375 

cats, and even for swine or larger animals if sufficient assistance be 
present, as it gives a better view of the abdominal cavity. 

The postmortem is begun by removing the hide, which has a market 
value and must not be injured. As scalpels and straight-edged knives 
are apt to button-hole the skin, a butcher-knife with rough cutting edge 
is to be preferred. Beginning at the angle of the chin a longitudinal 
incision is made down the median line the whole length of the body, 
avoiding the udder, prepuce, and scrotum, and the navel in the case 
of young animals. A transverse incision is made perpendicular to 
the first along the median surface of the foreleg and the skin is drawn 
back from the edges up over the dorsal surface. A similar cut is made 
upon the median surface of the thigh and leg down to the tuberosity of 
the os calcis. On both the limbs and the body the hair-seams will serve 
as a useful guide for the knife. A circular incision is made around the 
head from angle to angle at the lips. If the head is to be preserved, 
as in the case of a deer, the circular incision is made at the manubrium. 
The skin may be detached either with the hands or with the handle of 
a chisel. 

Removal of the Extremities. — After the animal has been 
skinned, it is placed on its side, and the uppermost limbs are removed 
in order to secure more room for subsequent manipulation. First the 
foreleg is held up by an assistant and the shoulder- joint disarticulated. 
The musculature of the part is cut through in the median portion by 
a butcher-knife grasped firmly by the whole hand. During the exsec- 
tion the extremity should be constantly raised by an assistant and the 
blade of the knife should be held somewhat towards the thorax so as to 
cut obliquely to the ribs. 

To remove the posterior extremity make a deep circular incision 
through the hip muscles, beginning with the broad crural fascia and 
above the large trochanter, passing up over and through the muscula- 
ture of the croup and downward and outward into the ischiatic fossa, 
5ut not behind the tuberosity of the ischium; raise the foot; cut 
through the adductors in a line with the acetabulum, open its capsular 
ligament, and section the round ligament. The incision of the capsular 
ligament is accompanied by a snapping sound, due to the entrance of 
air into the joint. The limb can now be drawn backward, the remain- 
ing fascia and muscles sectioned, and the whole removed. 

Exposure of the Abdominal Cavity. — Before opening the ab- 
dominal cavity of a filly the udder should be entirely removed from the 



;-,, POST-MORTEM EXAMINATIONS 

abdominal wall, and in geldings and stallions the scrotum and the 
penis should be isolated and thrown back. It should be remembered 
thai in herbivora meteorism occurs soon after death, so that the intes- 
tines arc pressed up closely against the abdominal wall and may easily 
be injured. 

The operator should stand in the space between the remaining 
extremities with his face towards the breast of the animal. An incision 
is made through the median line of the body, beginning with the 
en si form cartilage of the sternum, extending as far as the pubic region, 
cutting through the muscles and fascia only and not injuring the peri- 
toneum. This will not be difficult if the blade of the knife be held 
flat and the ball of the thumb placed near the edge and close to the 
point. As the peritoneum is carefully torn through with the fingers, 
the exit of gases, liquids, or abnormal contents of the abdominal cavity 
should be noted, as well as the position of the intestines. The index 
and middle finger are then separated so as to form a V-shaped space, 
in which the knife is placed and its point thrust through the abdominal 
wall along the line of the linea alba, the fingers following. At the 
posterior end of the longitudinal incision a second incision is made, 
perpendicular to the first, extending from the pubic region to the 
lumbar. The right upper half of the abdominal wall is held up by its 
edges with the left hand. The assistant pulls on the lower ribs in order 
to make the abdomen tense, and its covering is cut through with sawing 
strokes of the knife as far as the costal processes. The knife is so 
held by the whole hand that the point is shoved away from the operator 
towards the lumbar region and the lower part of the blade is used 
instead of the point. 

We have now a large anterior and a small posterior segment of the 
abdominal wall. They may easily be drawn back and a view of the 
abdominal organs obtained. The ribs of the horse extend so low down 
that a sufficiently extensive view for pathologic purposes cannot be 
obtained ; therefore, before removing the abdominal contents the tho- 
racic cavity is exposed. Then, by thrusting the hand well up under 
the lower ribs, we notice whether the diaphragm is tightly vaulted 
forward or is more or less relaxed. 

Exposure of the Thoracic Cavity. — A small incision is made 
between two of the true ribs and note is taken whether or not air enters 
the thoracic cavity and the diaphragm becomes relaxed. If the ab- 
dominal examination showed the diaphragm drawn down posteriorly, 



COMPARATIVE POSTMORTEMS 



377 



the incision should receive special attention ; instead of air entering, 
there may be an exit of gas from the pleural cavity, indicating some 
essentially pathologic condition. 

The direction for cutting the ribs is through the costal angles fol- 
lowing the course of the iliocostal muscle. An incision is made 



Temporomaxillary articulation 

after separation of half of the 
lower jaw 




Fig. 175.— Equine viscera, the animal resting- on its right side, the anterior and posterior left limbs 
having been removed, and the abdominal, thoracic, oral, and pharyngeal cavities opened. The double 
lines show the places in the intestines which are to be tied previous to being cut. 



between the true ribs and the blade of the saw introduced, an assistant 
making the breast tense while the sawing is done; very little pressure 
should be used or the bone will splinter. When the ribs have been 
sawed through, they are turned over towards the median line and 
removed by severing the costal cartilages. The situation of the organs 
and the pathologic contents should be carefully noted. (Fig. 175.) 



,- s POSTMORTEM EXAMINATIONS 

Removal of the Abdominal Contents in the Right Lateral 
Position.- -After exposing the abdominal cavity by the longitudinal 
and transverse incisions, pull the two left coils of the colon either up 
over the thorax or out across the body on the right side, so that the 
sigmoid flexure looks towards the head or lies on the ground and the 
body and tip of the caecum come into view. Spread the mesorectum 
out over the left flank and pelvic region. Stroke back the faeces, doubly 



Cut end of the rectum 



Spleen. 




Fi<>. 176. — Further dissection of animal seen in Fig. 175. Appearance of the parts after removal of the 
rectum, ileum, and jejunum. 



ligate the rectum at its entrance into the pelvis, and section. Cut away 
the mesorectum up to its origin at the rectoduodenal ligament, doubly 
• the rectum, section, and remove. 
The ileum is easily recognized by its thicker walls and its entrance 
into the cecum. Apply a double ligature, section, and, holding the 
intestine in the hand, cut away all the mesentery from the whole of 
the small intestine as far as the rectoduodenal ligament, divide this, 
doubly ligate the duodenum, and section. The junction of the colon 



COMPARATIVE POSTMORTEMS 



379 



with the rectum is now exposed, — the so-called stomach-like or gas- 
troid dilatation. — under which lies the anterior root of the mesentery. 
Grasping- the dilatation with the left hand (Fig. 176), pull it towards 
the caecum, and with the right hand work loose or cut partly away 
the connections between the gastroid dilatation and caecum and the 
omental sac, kidney, and pancreas. In this way better access to the 
portal vein and anterior root of the mesentery is obtained. With the 
fingers work through the cellular tissue surrounding the root of the 
mesentery, grasp it with the hand, and together with the portal vein 
cut it away close to the intestine, leaving as much of it as possible with 
the aorta. The colon and caecum are now drawn out of the cavity, all 
the remaining sections being easily torn or cut away, while the right 
branch of the pancreas which lies upon the caecum and the root of the 
mesentery must be carefully dissected away. Grasp the spleen, section 
the suspensory (gastrosplenic) ligament and the gastrosplenic omen- 
tum, and free the spleen from the stomach. Separate the branches of 
the pancreas from the larger blood-vessels and the kidneys, so that it 
hangs only by its body from the liver, and leave it in this position or, 
after examining its excretory duct, cut it away. Next remove the 
stomach and duodenum by cutting along the sigmoid curvature and the 
smaller curvature of the stomach and by sectioning the duodenorenal 
ligament, the hepatic and pancreatic ducts, the diaphragmatic and 
gastrohepatic ligaments, and the oesophagus, after pulling the latter 
down as far as possible from the diaphragm. Excision of the liver is 
an easy matter : section first the left lateral ligament, then the coronary 
and suspensory ligaments, the vena cava on the anterior surface of the 
liver, the right lateral portion of the coronary ligament, and the right 
hepatic and renal hepatic ligaments. 

Removal of the Abdominal Contents in the Left Lateral 
Position. — The rectum is sectioned at its entrance into the pelvis after 
pressing back the faeces with the fingers, applying a double ligature, 
and cutting between them. Seize the colon at its anterior curvature 
and pull it carefully out of the abdominal cavity as far as possible. 
The left folds of the colon will fall out with very little assistance. 

In the region of the kidney will be seen the arch of the duodenum 
lying between the anterior and posterior roots of the mesentery and 
covered by the ribs. Cut through this arch and its mesentery, after 
applying a double ligature, and remove. The cellular tissue lying 



3 8o 



POST-MORTEM EXAMINATIONS 



between the caecum and psoas muscle and the right kidney should be 
tfully worked loose and the pancreas separated from the caecum and 
the colon; this is done by tearing or cutting through the peritoneum 
ering the intestine and pancreas, getting the hand in under the 
pancreas, and working it loose. Beginning posteriorly, cut away the 
mesorectum from behind forward and any connections that may 
remain between the caecum and colon and the region of the kidney, 



Spleen 



Iliac spinal column 




Line for sawing ischio- 
pubic suture 



FlG. 177. — Further dissection of animal seen in Figs. 175 and 176. Appearance of the parts after removal 
of the large intestine. 

grasp as much as possible of the attachment of the mesentery, pull the 
intestine back away from the kidney, and section the root of the mesen- 
tery in front of the left hand, as far from the aorta as possible. With 
the exception of a small portion of the duodenum and the pelvic por- 
tion of the rectum the large and small intestines can be drawn out 
from the abdominal cavity by cutting or tearing away any attachments 
which may remain; the operator stands alternately at the back and in 
front of the cadaver while removing these portions. 

Removal of the Kidneys, Stomach, Liver, and Spleen. — The 
removal of the kidneys leaves a freer field for the stomach, spleen, and 
liver. With the hand and fingers separate first the right and then the 
left kidney and die suprarenal capsules from the surrounding cellular 



COMPARATIVE POSTMORTEMS 381 

tissue. If the ureters and kidneys are intact the kidneys may at once 
be cut away together with their vessels. In case of any abnormalities 
they should be left hanging or a sufficient length of the ureters removed 
with them, together with the surrounding tissues, or they may remain 
attached to their ureters and placed in the pelvic region. 

The pancreas, spleen, and stomach are freed from the mesentery 
and sectioned. The assistant pulls on the right side of the diaphragm, 
and the inferior vena cava between it and the liver is cut through 
together with the oesophagus and the right hepatic ligament. The 
stomach is turned backward. The left hepatic ligament is sectioned 
and all the three organs removed together in a mass. 

If the kidneys are left in place, the exenteration of the stomach, 
pancreas, and liver is more difficult and demands more caution, espe- 
cially if the animal has not been bled, because the field is obscured by 
blood and other impurities. Dissect away carefully the attachments 
of the right kidney to the suprarenal capsule and left branch of the 
pancreas, which lies deep down, covered by the branches of the mesen- 
teric arteries ; next the adrenals, then the fundus of the stomach from 
the crurse of the diaphragm, the suspensory ligament of the spleen, the 
splenorenal ligament, the right coronary and lateral ligaments of the 
liver, the hepatic renal ligament, the vena cava, with the falciform 
ligament, the oesophagus, and the left lateral and coronary ligaments 
of the liver. 

All these organs may be removed with the diaphragm, and, when 
there are adhesions to its posterior surface, this is the preferable 
method. The right lobe of the liver is first separated from the kidney ; 
the pancreas, spleen, and stomach are worked loose from the spinal 
column ; the posterior vena cava, the oesophagus, and the pulmonary 
attachments to the diaphragm are sectioned; the diaphragm is freed 
from the thoracic wall by a circular excision, and the whole mass 
removed together. Finally, the aorta and the venae cavae with their 
branches are dissected off the spinal column from the diaphragm to the 
pelvis. 

Exenteration in the Dorsal Position. — The body may be 
kept on its back by tying the feet to rings in the wall or to posts or 
poles. The extremities remain attached to the body, of course, and the 
broad muscles of the chest are only to be sufficiently incised to permit 
the anterior extremities to spring out a little and give access to the 
chest. If during the postmortem the extremities are released too 



,g 2 POST-MORTEM EXAMINATIONS 

much, the body will fall to one side and make the exenteration more 
difficult. 

A longitudinal median incision is first made, then a bilateral trans- 
verse incision just posterior to the last ribs. The two left folds of the 
colon arc drawn up over the right side of the body. The rectum is 
pulled out and spread over the left thigh and left ventral wall and the 
small intestine spread out over the region of the lower ribs. The ileum 
is found at its insertion into the caecum; it is thicker than the rest of 
the small intestine. It is tied off and sectioned, remaining in the hand 
after its mesentery is severed close up to the intestine. In this way the 
whole of the right lateral small intestine is removed from the abdomi- 
nal cavity and its mesentery left hanging by its root. When it passes 
into the duodenum between the two roots of the mesentery, doubly 
ligate and section. Doubly ligate and section the rectum at its entrance 
into the pelvis and' again at its junction with the colon. 

The pancreas and first part of the duodenum are dissected away 
from the colon as in the first method. The roots of the mesentery and 
both the branches going to the large intestine are sectioned close up 
and the large intestine is removed. 

The stomach, spleen, etc., are removed as in the first method. 
Many operators prefer to excise the spleen and open the stomach along 
its greater curvature and the duodenum on its inferior surface, where- 
upon the pathway of the bile-ducts may be determined and then the 
empty organs cut away. 

In the dorsal position the thoracic organs may be ablated by draw- 
ing them down towards the abdominal cavity. An incision is made 
between the rings of the trachea, two fingers are inserted, the trachea 
is grasped firmly, and the larger vessels are sectioned at the thoracic 
inlet; the aorta is dissected away from the vertebrae and the posterior 
vena cava and oesophagus are sectioned. If it be desired to remove 
the thoracic viscera together with the trachea and cervical organs, the 
first rib is sawed through and excised; the cervical organs are then 
ablated according to the method to be described later. 

Vienna Method of Exenteration in the Left Lateral Posi- 
TION. — Csokor's quick method for removing the thoracic and abdomi- 
nal contents is as follows: The extremities are removed and the 
abdominal cavity is exposed by a longitudinal and a transverse incision 
as in the first method; then the muscles of the back are cleared away 
and the sectioned abdominal wall is drawn up by a hook. With a 



COMPARATIVE POSTMORTEMS 383 

hatchet each rib is cut away from the spinal column and then from the 
breast-bone. The whole right wall of the thorax and abdomen is now 
drawn up over the head of the animal and the contents of both cavities 
are exposed. The right kidney is next removed and then the thoracic 
contents. After their ablation the cardiac end of the stomach is freed 
from the diaphragm and the duodenum is detached from the liver and 
its surroundings and excised together with the stomach and spleen. 
The abdominal aorta is separated from the spinal column, the rectum 
sectioned, and all the intestines removed. The remaining organs are 
extirpated as in the other methods. This modification permits a very 
rapid necropsy, but the removal of the stomach and spleen is somewhat 
difficult. 

Discission of the Abdominal Contents. — To ascertain the 
macroscopic conditions of the abdominal contents it is necessary to 
make a few special incisions. The aorta is first examined and its dorsal 
wall slit up with the shears to expose the entrances into its branches, 
which are then cut open. On account of its great frequency, close 
search is to be made for an aneurism in the root of the mesentery. It 
is usually felt externally as a thick, cystic expansion. The branches to 
the small intestine — the duodenal, jejunal, and iliac arteries — are first 
given off from the short trunk of the artery lying in the root of the 
mesentery (the anterior mesenteric artery) ; next a large vessel, the 
ileocolic artery, which gives off a large branch, the inferior colic, and 
the ileocecal artery with its three branches. The superior colic comes 
off above the root of the mesentery on a level with the anterior rectal 
artery. After examining these branches slit the inferior and superior 
colic arteries in the mesocolon from their origin to the sigmoid flexure, 
If it seems necessary, examine the arteries of the small intestine in 
the same way and observe the mesenteric lymph-nodes. The bowel is 
opened with the shears along the line of the attachment of the mesen- 
tery so as to get a good view of Peyer's patches; keep the intestine 
lying flat, for if held up the contents run down into the lower portions, 
which is a nuisance. 

If the stomach is sufficiently full, cut it open with a knife along its 
greater curvature. If the duodenal portion remains with the stomach 
and liver, open it with the shears on its inferior surface in such a way 
that the termini of the hepatic and pancreatic ducts will not be injured 
and their patency may be demonstrated. Press and push along the 
course of the ducts so as to force out their contents. If there is any 



POST-MORTEM EXAMINATIONS 

licion of abnormalities in these ducts, it is better to leave the 
Stomach and duodenum in place and to open them before removal. 

Removal of the Thoracic Contents. — First carefully examine 
for sharp points of bone and excise them with cutting forceps. The 
pericardium should then be examined and worked free with the hands. 
The posterior vena cava is tied off and divided between the ligature 
and the diaphragm; the attachments of the liver and heart to the 
diaphragm are sectioned and an incision is made obliquely through the 

ta down to the vertebral column. Thrust the finger into the pos- 
terior aorta, pull it up, and cut along the spinal column in the line of 
the vena azygos and the attachment of the longus colli. Now make 
an oblique section through the oesophagus, trachea, anterior aorta, and 
anterior vena cava along the line of the first rib, so that the thoracic 
organs may be removed. This avoids cutting the large veins, which 
bleed so freely as greatly to obstruct the view of the parts under ob- 
servation. 

Section of the Oral Cavity and Cervical Organs. — This is 
begun by removing the ramus of the lower jaw on one side. Cut the 
buccal parietes and the cheek at the angle of the lips up to the zygo- 
matic arch, between the molar teeth and the space between the lower 
jaw and the large maxillary swelling, dividing the masseter and saw- 
ing through the bones. The ramus of the jaw may now be worked up 
and down, its muscular connections severed by a knife introduced 
along its median surface, and an incision made between the parotid 
gland and the posterior border of the bone. The temporal muscle is 
cut through above the coronoid process and the ligaments and capsule 
of the joint are sectioned, the jaw being moved up and down to find 
the joint. After examining the local conditions, sever the left connec- 
tions of the tongue with the jaw and the soft palate; saw through 
both to the large branches of the hyoid bone. The larynx, trachea, 
and oesophagus are easily freed from their loose cellular tissue by 
cutting into the channel of the external jugular vein, between the 
longus colli muscle and the oesophagus, so that the thyroid gland is 
not injured. 

Dissection of the Thoracic and Cervical Organs. — In order 
more closely to inspect these organs, cut through the vault of the velum 
palati with the shears and continue down into the oesophagus, section- 
ing it dorsally. With the knife grasped firmly incise the larynx in the 
median dorsal line between the arytenoids. Pushing the oesophagus 



COMPARATIVE POSTMORTEMS 385 

aside, cut the posterior muscular ligament of the trachea with shears 
throughout its whole length and thrust the cartilages apart to get a 
good view of the interior. The lobes of the lungs are laid open with 
long, deep, bisecting strokes, and portions of each lobe are tested by 
throwing them into water to see whether they contain air and will 
float or will sink because of collapse or the presence of an exudate. 
The lymph-nodules around the roots of the bronchi should always be 
examined and sectioned. 

If the heart is hacked into or improperly opened, the distinctive 
appearance of any abnormality that may be present is destroyed, and 
these anomalies are of great importance to the whole organism. First 
make an incision into the right ventricle along the septum, insert the 
shears, and cut up into the pulmonalis. Holding the heart by this flap, 
lengthen the incisions towards the apex and the flap so as to get a 
better view of the ventricle. In the same way incise the left ventricle 
close to the septum and on the anterior surface ; insert a finger through 
the opening, find the entrance into the aorta, and with the shears cut 
down between the pulmonalis and the left auricle. It is true that in this 
way both semilunar valves are sectioned, but the auriculoventricular 
valves are spared and they are much more likely to present abnormali- 
ties than the semilunar. The size of the openings can be tested by 
inserting a finger, and the thickness of the walls measured, after which 
each auricle is cut through up into its vessels and a good view of their 
openings obtained. 

Exexteratiox of the Pelvis. — The removal of the pelvic organs 
is preceded by the previously described excision of the kidneys and 
ureters and in males by the exposure of the testicles and the external 
genitalia. The scrotum and penis were then turned back, and now 
their dorsal suspensory ligament and surroundings are divided as far 
as the ischiatic notch and all the flesh lying ventrad to the ischiatic 
suture is carefully cleaned away. The scrotum and the right and left 
inguinal canals are split open and the testicles together with the sper- 
matic vessels pulled up into the abdomen. It is especially necessary 
to cut the tendinous ligament which binds the corpora cavernosa to the 
ischium close to the bone, as well as the strong ischiopenile muscle. 
Two sections made by sawing will remove the right wall of the pelvis. 
The first one is made through the ischiopubic suture over the aceta- 
bulum to the iliac spinal column; the second, through the thin part of 
the iliac bone, after cutting away the flesh that lies over the acetabulum 

25 



POST-MORTEM EXAMINATIONS 

on the iliac column. By cutting the bone loose from the pelvic cellular 

lie, it is easily pulled away. 

The lateral wall of the pelvis being removed and a good view of 
the organs obtained, divide the connective tissue between the rectum 
ami the superior pelvic wall; free the uterus and ovaries, the neck of 
the bladder, the vagina, and the accessory sexual glands; cut through 
the strong rectococcygei and the skin between the tail and the anus; 
and make a circular incision around the anus and the vulva (or the 
region of the penis). Remove the whole mass and section the organs 
dorsally. 

Exenteration of the Cranial Cavity. — To remove the head 
from the trunk we may either cut around the joint as if the throat were 
being cut or puncture the capsule ventrally and amputate between the 
condyles and the atlas. It is best to remove the whole of the lower 
jaw and let the skull, wrapped in a cloth, rest on its base and the molar 
teeth ; it may then be held much more steadily than if the inferior 
maxilla had been left in place. The cranial attachments of the cer- 
vical and temporal muscles are next cut away and the soft parts re- 
moved from the roof of the skull. 

There are three lines for sectioning the cranium. The first lies 
transversely across the forehead about a thumb's breadth above the 
upper border of both superciliary ridges. The tw r o other lines begin 
at the ends of the frontal incision, pass backward across the temples 
and petrous bones, and converge to the condyloid apophyses (Figs. 
[78, 1 ~<j > . The first section can be made continuously, but the second 
and third will have to be done in several portions on account of the 
convexity of the cranium. 

The walls of the cranial vault are not equally thick, and care must 
be taken not to penetrate too deeply into the middle of the parietal 
- and the squamous portion of the temporal bones. The frontal 
sect: - through the frontal sinuses, so that there is very little 

danger here; and the same is true of the vertex and the pyramidal 
region above the condyles. The plates are not usually sawed clear 
through along the whole line, but the connections are broken with a 
chisel. Rest the palm of the hand upon the skull, grasp the chisel 
firmly near it- edge so that it cannot enter too deeply, and tap gently 
with the hammer. When the bones are completely severed, pry the 
piece off by rocking the chisel backward and forward, first in the 
frontal and then in the condylar region. A sudden strong pull on the 



COMPARATIVE POSTMORTEMS 387 

pericranium, grasping it at the edge of the frontal section, will gen- 
erally separate it from the other parts of the head; sometimes the 




Fig. 17S. — Lines to guide the saw in opening the cephalic cavities of a horse. 

whole brain will come away at one jerk, together with the root of the 
skull. 

If the dura is too closely held or is adherent to the inner table of 




FIG. 179.— Lines of sawing for opening the cranial cavity oi a horse. 

the skull, with the shears incise it in the line of the section in such a 
manner that the dorsal portion will come away with the calvarium. 



,gg POST-MORTEM EXAMINATIONS 

Next excise the longitudinal and transverse blood-vessels in the duras. 
That part of the dura lying over the hemispheres is held up with 
Forceps and cut with scissors so that it may be thrown back on both 

5. The tentorium is sectioned anteriorly and posteriorly and re- 
moved. The membranous transverse septum which is torn away from 
the falx is incised laterally and pulled out from the transverse fissure, 
due attention being paid to its vascularity. 

Dissection of the Brain. — After examining the pia mater and 
the superficial surface of the brain, the hemispheres should be separated 
so as to expose the corpus callosum. The interior of the brain may 
either be examined now or after its removal. A horizontal incision is 
made immediately over the corpus callosum, starting at the median 
surface, and using preferably the so-called " brain-knife" or a long, 
flat scalpel. If the incision is not quite deep enough to enter the lateral 
ventricle, you will come first to the so-called " egg-shaped middle 
point" (centrum semiovale Vieussenii) ; press this gently with the 
finger and you will find a yielding point which, when incised, opens 
into the lateral ventricle. Follow the finger with the knife and slit 
open the roof anteriorly and posteriorly. Look for a collection of 
fluid, and examine the choroid plexus, corpora striata, horns of the 
ventricle, and median septum. This is seized in the middle, raised a 
little, sectioned transversely, and thrown back, the connections holding 
it to the peduncles being severed. Now carefully insert four fingers 
into the transverse fissure and raise the posterior lobes in order to 
expose the corpora quadrigemina, optic thalami, pineal gland, and 
middle choroid plexus. By separating the two thalami a little, you can 
divide the commissura mollis and see into the third ventricle. 

To remove the brain, support the skull upon the incisors in such 
a position that the condyles look upward and the brain would fall out 
if it were free. Into the space thus obtained between the medulla and 
the base of the skull, insert a finger, the closed scissors, or the handle 
of a scalpel, and sever the nerves one by one as they appear. The 
olfactory bulbs, which are unusually large in comparison with those 
<«f man. are worked out from the ethmoidal depressions by a circular 
thrusting m< >tion of the handle of the scalpel. When they are all sepa- 
rated, the brain will fall into the waiting hand, which must steady it 
constantly or the olfactory bulbs would be torn away by its falling 
out too soon. 

After the brain is removed, the inferior surface is first examined, 



COMPARATIVE POSTMORTEMS 389 

then, turning the brain over, the cerebellum is cut into halves. Expose 
the fourth ventricle and incise the floor longitudinally. With a thin- 
bladed knife cut radially to the cortex and transversely to the crurae, 
making numerous narrow incisions to detect the presence of any small 
hemorrhage or other lesion. 

Removal of the Spinal Cord. — This requires much time and 
labor when properly done, but is managed in various ways. But little 
time is spent in routine work when you have a butcher to assist you. 
The animal is suspended and the vertebrae are split off from their 
bodies by a hatchet ; when this is cleverly done, the line of cleavage 
being kept a little to one side, the cord is but slightly injured. It is 
better, however, to proceed as follows : Saw off the ribs at their angles, 
separate the ilium from the sacrum, and clean off all the flesh. Laying 
the spine upon the table, begin at the pelvis and chisel off the vertebral 
arches, remembering that two chisels are necessary, one for each side, 
as the two instruments have different curves (Fig. 37). If an ordi- 
nary chisel is used, the arches should be partially sawed through to 
make their division easier. The hand holding the chisel supports itself 
on the spine, and the chisel is held as flat as possible while an assistant 
grasps the spinous processes and springs the arch apart. You may 
also expose the spinal canal ventrally by sawing through the vertebral 
bodies and arches on one side only. Section the nerves at their points 
of exit laterally to the intervertebral ganglia and lift out the cord 
enclosed in its membranes. Cut open the dura with the scissors and 
section the cord transversely with a sharp, thin knife. 

Exposure of the Accessory Sinuses. — To expose the nasal 
fossae saw the head in two, after removing the brain, a little to one 
side of the median line so as not to injure the septum on either side. 
These fossae may be sectioned transversely or their walls chiselled away 
to show the accessor}' sinuses. Csokor saws through the osseous struc- 
ture of the nose transversely from the level of the malar or lachrymal 
bone to the roots of the molars; a section is then made horizontally 
beginning at the anterior nares and joining at the first section (Fig. 
»:i raising this cap you have the maxillary, nasal, and frontal 
well exposed. 

One or two long bones should be sawed through to judge of the 
condition of the bone marrow. 

. mortems ox RuMlNANTS. — There are certain peculiarities 
in the skulls of ruminants which must be remembered when exposing 



;,oo 



POST-MORTEM EXAMINATIONS 



the cranial cavity. It is only in very young animals that the cranial 
bones possess diploe, and in necropsies on hornless cattle the incisions 
arc the same as for horses. On account of the prominent crests, which 
fall away very abruptly, and because a calf's head is somewhat rounder, 




Fig. 180.— Lines used in sawing in order to expose the cranial and nasal cavities in a ruminant. 

the sawing will have to be done in more segments, and great pains 
must be taken on account of the thinness of the bones. The older the 
animal the larger are the hollow places between the internal and ex- 
ternal plates ; the diploe disappears and only a few crusts and plates 




FIG. i^i.— Appearance of cranial cavity of a cow after removal of the bony vault. 

of l)one interrupt the hollow spaces. The lateral and posterior portions 
of the skull are very prominent because of two large crests. The 
transverse section is nearly coincident with the posterior border of the 
superciliary ridges. The lateral sections are made in two segments, 



COMPARATIVE POSTMORTEMS 



391 



beginning at the ends of the transverse frontal incision and passing 
back over the temples to the foramen magnum. Clement has devised 
a better method (Figs. 180 and 181). First clear away all that part 
of the calvarium formed by the frontal eminence and the lateral 
depressions by sawing through the skull in a line passing from just in 
front of the horns obliquely backward and downward to the condyles 
or foramen magnum. After removing this plate of bone the whole of 
the posterior portion of the brain is exposed. Next make a transverse 
incision on a level with the superciliary ridges across the anterior end 
of the cranial cavity. Finally make two short longitudinal incisions, 
one on each side, about three centimetres from the median line; with 
mallet and chisel remove the oblong piece enclosed, and the whole 
brain is exposed. The curved horns of a sheep or a goat serve as 
convenient handles for removing the calvarium and may very well be 
left on, while the horns of neat cattle should be knocked off. 

Postmortems on Swine. — With the body lying on its left side, 
the right extremities are removed, the abdomen is exposed by longi- 
tudinal and transverse incisions, the diaphragm observed, and the 
lateral thoracic wall divided by cutting with the bone-shears or sawing 
through the angles of the ribs and severing the cartilages close to the 
sternum. To remove the abdominal contents, first find where the 
duodenum is attached to the rectum; sever the duodenorectal liga- 
ment, separate the pancreas from the mesentery, and section the duo- 
denum. The anterior root of the mesentery is loosened by working 
it free with the hand and pulling on it, then sectioned, the whole of the 
mesentery excised from before backward, and the rectum divided. 
Xow cut away the spleen from the stomach, examine the opening of 
the bile-duct, section it and the oesophagus, and separate the stomach 
from the diaphragm, leaving the liver freed from its suspensory liga- 
ment. The thoracic and cervical organs are removed as with other 
animals. 

In old quadrupeds the brain lies very deep, because of the immense 
air-spaces in the cranial bones which surround the brain on all sides 
except the temporal region. The transverse section is made a full 
thumb's breadth above the superciliary ridges (the eyes being first 
removed; and the lateral sections run back to the occipital foramen. 
Instead of a transverse section we may make two oblique ones, begin- 
ning at the posterior border of the frontal process and joining each 
other and the lateral incisions in the anterior frontal region. 



39 2 



POST-MORTEM KXAM1NATIONS 



Postmortems on Dogs and Cats. — The necropsy of a dog is 
easily and quickly made in either the dorsal or the left lateral position. 
The procedure is the same as for the horse, but it is not necessary 
to remove the extremities entirely or to take off the hide; simply cut 
through the muscles enough to allow the limbs to fall away a little 
and the body will be sufficiently steady. (Figs. 182, 183.) The thick- 




-2.— Postmortem of the dog. Double lines show places at which the intestines are to be tied ; the 
dotted line indicates the direction for incising the mesentery. 



ening at the junction of the cartilages with the ribs is easily felt, the 
articulations are cut, and the sternum is pushed upward and forward 
after freeing the pericardium and the pleura. Section the tracheal 



COMPARATIVE POSTMORTEMS 393 

vessels and oesophagus at their entrance into the thorax and remove 
the thoracic organs. 

The removal of the abdominal contents of a dog is easy. Divide 
the rectum at the pelvis and the two mesenteric roots, and the abdomi- 
nal aorta and inferior vena cava behind the liver; thrust the hand in 
between the liver and the diaphragm, and with scissors section the 
suspensory ligament of the liver, the vena cava, and the oesophagus 
after it is pulled down from the diaphragm and tied off or compressed 
with the fingers. All the abdominal contents may now be removed 
together. Spread them out, examine each again, test the patency of 
the bile-ducts, and straighten out the bowels. It is, however, better 
first to remove the intestine, which is sectioned through the duodenum 





Fig. 183. — The left ramus of the mandible has been removed and the tongue pulled outward and down- 
ward, thus exposing the oral and pharyngeal cavities in a dog. 

at the pancreas and through the rectum at the pelvis. You may next 
either remove the liver with the stomach, or after inspecting the bile- 
ducts you may cut away the stomach from the oesophagus and duo- 
denum and then remove the liver. 

To expose the cranial cavity we have the same three lines as usual, 
the transverse section lying directly posterior to the rudimentary super- 
ciliary ridge, crossing the frontal sinuses and the anterior lobes of the 
brain. The anterior temporal and the parietal bones are not thick and 
contain diploe, so that the sawing must be carefully done. Since the 
petrous portion of the temporal bone has deep impressions upon its 
internal surface, in which convolutions of the cerebellum lie, and since 



,,,, POST-MORTEM EXAMINATIONS 

the bony processes project from the adjacent bones, great care must 
be taken not to tear the cerebellum. In small dogs with round heads 
the line for sectioning is more nearly a circular one. 

The postmortem o\ a cat is made in the same way. 

Post-mortem Examination of Birds. — Plug up the nostrils, 
mouth, and vent with cotton; make an incision from the point of the 
breast-bone, or a little above, backward to and through the anterior 
portion oi the anus, leaving the uropygium (pope's nose). Loosen 
each leg to the knee (above the femur) by tearing the soft parts with 
your thumb and fingers, then cut with a knife until they meet around 
the pelvis at the rump. With your thumb-nail work the wings loose, 
hold the skin firmly, and, pressing your nail towards the body, cut off 
the wings at the elbow. To get at the brain make a V-shaped slit with 

ipex inwards the median line at the foramen magnum, running 
up towards the centre of the skull ; the brain is then removed attached 
to the cord, and the skin is kept whole for taxidermic preservation. 
The " wish-bone" in birds is the joined clavicles. 

Post-mortem Records. — Kitt suggests the following scheme for 
the more intelligible recording of the findings in postmortems on the 
lower animals. 

RECORD OF NECROPSY. 

Species Gender Age Color of hair Owner 

Clinical history Treatment Mode of death Date of death 

Necropsy performed by Where performed Date 

Order of Persons present 

A. — External Examination. 

Position of the cadaver (on back, right or left side, hanging) 

Nutritional condition (weight) 

Removal or absence of parts 

Rigor mortis 

Condition of the skin and its appendages (the skin around the head, trunk, and 
extremities ; the horns, claws, hoofs, ears, scrotum, prepuce, udder) 

The natural body openings and visible mucous membranes (the discharge of foam, 
fluids, and excrementa; the color of the lips, nasal mucous membranes, con- 
junctivae, anal and vaginal mucosae) 

B. — Internal Examination. 
obtained in removing the hide 

ion (,\ subcutaneous tissues, fat, lymph-nodules, vessels, extravasated blood, 
muscles, ligaments, tendons, fascia, joints, and bones 
Abdominal and thoracic data 

Condition of diaphragm, position of organs, appearance of peritoneum, mediasti- 
nal and costal pleurae, and pericardium 



COMPARATIVE POSTMORTEMS 395 

The oral cavity, tongue, teeth, soft and hard palate, salivary glands, pharynx, Eu- 
stachian tubes, oesophagus, retropharyngeal and laryngeal lymph-nodules 

The larynx, trachea, thyroid, and surroundings 

The lungs, bronchi, bronchial lymph-nodes 

The pericardial sac, heart, and thoracic vessels 

The liver and bile-ducts, portal vein, and periportal lymph-nodules 

The spleen (capsule, pulp, trabecular, Malpighian bodies, and vessels) 

The stomach and crop 

The pancreas ; the large and small intestines 

The mesentery, omentum, posterior aorta and its branches, and vena cava 

The kidneys, adrenals, ureters, capsule and pelvis of the kidney, and its half 
section 

The urinary bladder, urethra, and accessory sexual glands 

The pelvic portion of the rectum 

The genitalia: uterus, vagina (pregnancy, fcetal membranes, embryo), and the 
male genitals 

The cranial cavity and the brain : calvarium, sinuses, cavities at the base of the 
skull, dura, cerebral superficies, ventricles, gray and white matter 

The eyes ; the middle and internal ears 

The fourth ventricle and the spinal cord with its membranes 

The nasal fossae and accessory sinuses 

The udder and supramammary lymphatic nodules 

The bone marrow- 
Microscopic and chemical report 

Inspection of Special Organs. — The essentials for diagnosis 
which are to be looked for and recorded are about as follows : 1. Name 
of the organ; from what animal; whether it died or was killed; 
whether the organ was entire or fragmented; whether parts, lobes, 
etc., have been amputated; and if there are any adhesions to adjacent 
parts. 2. Weight. 3. Length and breadth of the part. In the ab- 
sence of a tape measure we may ascertain these dimensions approxi- 
mately by comparison with the breadth of the hand and the length of 
the finger. Every person should know the length of his index-finger, 
which is usually about ten centimetres and may be used to measure 
organs, pathologic spots, streaks, canals, etc. 4. Surfaces : whether 
smooth, even, wavy, granular, corrugated, rough, transparent, or 
cloudy. Color of the surface: general and primary color, special 
deviations and shades. The external contour of the organ and any 
prominences, with especial reference to their size as compared with 
grains of sand, millet-seeds, lentils, peas, beans, hazel-nuts (or filberts), 
a pigeon's, a hen's, or a goose's egg, the fist, the thickness of a child's 
arm, a child's head, etc. (Plate II.) 5. The consistence as deter- 
mined by palpation: soft, elastic (like the lungs), doughy, splenified, 
hepatized, tough, inelastic, carnified, indurated, leathery, like the kid- 



»n6 POST MORTEM KXAMINATIONS 

neys and skin, as bard as wood, cartilage, bone, or stone. 6. Section- 
ing of special parts: through the compact, so-callecl parenchymatous 
organs (muscles, liver, kidneys, lungs) large dissecting incisions are 
made. Through the brain and heart sections must be made in a certain 
way in order properly to expose certain cavities. On sectioning notice 
the resistance of the tissue, whether it cuts easily or is tough and pulls, 
whether the knife creaks as it goes through, whether the tissue is so 
hard that a saw is necessary, and observe if any fluid follows the sec- 
tion or if there are any abnormal contents. The surfaces of the section 
must be noted, their color, thickness, consistence, fluidity, and vascu- 
larity, as well as any other peculiarities which may be present. The 
pathologic diagnosis is made by considering the details gained in this 
way, which lead to one conclusion and exclude another. A gross ana- 
tomic diagnosis is often only provisional and dependent upon micro- 
scopic and chemical confirmation. 



CHAPTER XXVI 

MEDICOLEGAL SUGGESTIONS 

Although a physician is not expected to have a profound knowl- 
edge of legal matters pertaining to his profession, yet every doctor 
should be more or less familiar with the medical laws of the State or 
country in which he is practising. He should be well acquainted with 
the regulations of the board of health, of the coroner's office, of the 
criminal court, etc., and' do all in his power to aid in their rigid 
enforcement. A synopsis of such laws and regulations is usually 
readily obtainable in book form, and nearly every physician has among 
his patients or friends a lawyer who is glad to discuss legal questions 
in return for medical information. Some of the salient points relating 
to medicolegal investigations and autopsies will here be briefly con- 
sidered, though many references to these matters will be found else- 
where throughout this work, especially in Chapter XXVII. 

- Obligations of Physicians to their Patients. — The obliga- 
tion of a physician to society in the practice of medicine is in a certain 
sense voluntary. His is the right to refuse any and all cases that may 
apply to him for treatment or advice. Services once begun, however, 
he must, after giving notice of his intention to discontinue them, allow 
his patient reasonable time to fill his place, as otherwise he renders 
himself liable for damages. This obligation is equally binding in 
the case of charity patients. Contracts between a physician and a 
patient may be either express or implied. An express contract is where 
services are rendered in accordance with a definite agreement previ- 
ously entered into between the parties. There is the promise of 
proper treatment in an implied contract just as there is the promise of 
payment. Generally, however, the contract is implied by the law 
from the fact of employment and consequent attendance. Both forms 
■ .f contract are equally binding, and both are subject to public policy. 
Contracts making the payment contingent upon successful treatment . 
are valid, but, should the patient fail to follow the doctor's directions 
r.r to give him sufficient opportunity for treatment, the Court would 
probably allow the latter reasonable compensation. If the physician 
fail to exercise ordinary skill, he renders himself liable for malpractice. 

397 



398 



POST-MOR 1 EM i:\AMINATIONS 



hi law malpractice consists in the failure to possess or use such ordi- 
nary knowledge or skill as is generally possessed and used by physi- 
cians and surgeons in similar localities, whereby injury accrues to the 
patient. The term is also applied t<> acts which are expressly forbidden 
Statute. The average physician is not bound to possess the highest 
expert skill nor is his implied contract one binding him to effect a cure; 
he must simply treat the case with reasonable skill, diligence, and faith- 
fulness. That done, he cannot be held accountable for results. Births, 
deaths (with their probable cause), and infectious diseases are to be 
reported t<> the proper authorities for registration. In hiring a wet- 
nurse for a syphilitic child the woman must be informed of the fact 
that the infant is specifically infected and of the risk that she runs in 
taking it to nurse. It is a criminal offence to practise medicine or 
surgery while intoxicated. 

The obligations of a patient to his physician, in so far as they 
relate to the treatment given, are indefinite and more or less vague. 
They can hardly be considered to come within the province of exact 
definition. The patient should conform to the directions given him, 
but no legal liability arises if he does not: the risk is his. If in such 
circumstances the attending physician is of the opinion that his advice 
eing disregarded, to the detriment of his patient and perhaps of 
»wn reputation, he is always at liberty to withdraw from the case 
and to require that another physician be called in. 

A- to compensation, it may be laid down as a rule that in the 

special contract the measure of the liability of the patient 

to his physician is the customary charge made by others of equal stand- 

niilar services. The question of compensation is a broad one 

and its full treatment is beyond the scope of this work. It may be 

remarked, however, that the specialist should protect himself by an 

contract. Physicians should also be careful to have their 

tints so kept as to be able to use them as evidence if dispute should 

Much trouble and loss are frequently caused by neglect in the 

ries made by physicians in their books. In the case of Laffin vs. 

Billington, the Appellate Term of the Supreme Court of New York 

►ntract by a physician to give expert testimony for the 

plaintiff in a personal-injury case and to receive as his pay therefor a 

of any amount realized is invalid. 

Expert Testimony. — Applying these principles pertaining to 

medical pt our subject, no Court can compel a physician to 



MEDICOLEGAL SUGGESTIONS o n 

399 

give expert testimony, to make autopsies, or to conduct laboratory 
investigations without his consent, but any knowledge which the 
doctor may possess pertaining to an individual criminal case must be 
given to the Court in the same manner as if he were an ordinary 
witness. His scientific training is, however, his own personal property, 
the result of many years' study, careful research, and expenditure of 
money, and he is entitled to commensurate remuneration for the expert 
use of his knowledge. For the good of society, any facts pertaining 
to a given criminal case which are known to him should be freely and 
willingly given to the Court, though he thereby may be put to consid- 
erable loss of time and money. The expert should be cautious in 
expressing opinions before the case is called for trial. (Wormley.) 
Thus, in the Williams case, tried in Philadelphia in 1903, I was asked 
by the district attorney while on the witness stand if I had ever ex- 
pressed to the attorney for the defence an opinion as to the cause of 
death, and, if so, what that opinion was. 

Whether the Court will compel him to divulge professional secrets 
is a debatable question. In some States and countries such confidences 
of the patient are held sacred, as are the relations between counsel and 
client; while in other places such confidences (wrongly, we believe, 
in civil cases, but rightly in first-degree criminal cases) must be 
divulged to the Court should questions pertaining to the same be 
asked the physician while on the witness stand. The matter is one 
for the Court to decide, and such decision being given absolves the 
witness. Whether the prescription of a physician is a privileged com- 
munication is a matter of much debate, the weight of opinion, probably, 
being that it is not. 

An expert is one who by reason of his peculiar experience, special 
study and training, or the performance of certain duties, is competent 
to ascertain particular facts of a technical nature or to form an opinion 
or judgment upon them, such as could not be expected from the judge 
or jury. Xo ordinary witness is permitted to express an opinion upon 
the facts as presented to him, as this is supposed to be the province of 
the members of the jury. Thus, in one of my cases, where infanticide 
was suspected, an iceman had found the dead body of the baby in an 
ash-barrel, and the judge would not permit the iceman to act as an 
expert in giving the approximate weight of the child, though it would 
^eem that, on account of his frequent weighing of ice. he would be 
more fitted to give a correct estimate of the weight than an ordinary 



POST MORTEM KXAMINATIONS 

person. The weight of the child (nine pounds) was desired in order 
to show that it was born at or near full term. 

The jury is supposed to arrive at a decision as to the point at issue 

from the facts proved before it. and hence must necessarily form an 

opinion thereon. Where, however, there arise in the case technical 

natters involving special knowledge, as to which persons in 

era! are not qualified to reach a correct judgment, and where, 
therefore, the opinion of those versed in such knowledge is neces- 
sary to the formation of a proper verdict, — in such case experts are 
allowed to testify. In so doing they must frequently give their judg- 
ment as to the facts, often presented to them in the form of hypo- 
thetical questions. Such questions are presumed to be framed from 
the testimony already accepted. Great care should then be exercised in 

Fying, especially as sometimes the ingenuity of counsel is used 
so to formulate the hypothetical question as to confuse the issues in 
the mind n\ the jury or to extract from the witness evidence contrary 
to the true state of the case. 

A medical man should refuse to testify as an expe'rt unless he is 
thoroughly qualified. In no case should he go on the witness stand 
without being as fully informed as is possible on the subjects on which 
a mined, nor should he allow himself to be questioned on 
subjects < »n which he is not prepared. He should be honest and candid 
with those securing his services before the trial, and, no matter what 
may he the consequences, his answers while on the witness stand must 
he made with absolute impartiality. Upon a suit for damages an 
rt may he held responsible for errors which he may have com- 
mitted in the performance of his work. Thus, a chemist passing glu- 
Free from arsenic might have to pay damages, should beer 
he made out of the glucose and arsenical poisoning result therefrom. 

The medical expert should at all times confine himself to purely 

medical topic and never become involved with matters that will place 

him in the light of an ordinary witness, of a detective, or of an 

and he should carefully avoid acting as a champion of the 

parties who are paying for his services or attempting to plead one side 

of the I 

language should he as free as possible from technicalities and 

Mich as can readily he followed by the least educated of the twelve 

whom are only too often, unfortunately, unfit for the 

•f their duties. Some judges carry this plainness of Ian- 



MEDICOLEGAL SUGGESTIONS 4 Oi 

guage to an extreme. Thus, while acting as an expert in a murder trial, 
the writer was once requested by the judge not to use the word " hem- 
orrhage" in testifying, as this term was too technical for the jury to 
understand. I at once substituted " bleeding" for the objectionable 
word and proceeded with my testimony. When not absolutely certain 
of a point he should unhesitatingly acknowledge the fact; thus harm 
and the possible endangering of a human life will be avoided. But 
when sure of his ground he should undeviatingly adhere to it. At the 
close of his testimony, especially if long and exacting, an opportunity is 
almost always given him to correct any misstatements which he may 
inadvertently have made, and to make clear the meaning of any dubious 
points of his original testimony which may have been clouded by the 
cross-examination conducted by the opposing counsel. 

Too much is often expected from the expert, as the following 
instance shows. While testifying as an expert in a country town on 
a case where the postmortem revealed beneath the left eye a small 
incision closed with two stitches, ecchymoses about the eyeball, and a 
fracture of the skull, the district attorney and the judge criticised 
me severely because I would only state that the man had died from 
hemorrhage of the brain due to fracture of the skull. They desired 
me to say that the man had been knocked down with the fist of a 
person who had a ring upon his ring-finger, and that in this manner 
the cut and the fracture had been produced. I was naturally willing 
to say that they could have been made in this way, but would not state, 
apparently much to their disappointment, that they were so caused. 

Medicolegal Postmortems. — The objects of a medicolegal post- 
mortem include the finding out of the cause and mode of death, the 
establishment of a corpus delicti, the determination as to whether a 
crime has been committed, and if so the discovery of a motive therefor 
and the exact nature of the process employed therein. In such legal 
investigations the pathologist should protect his reputation in every 
possible manner, and he ought to hesitate to make a postmortem with- 
out the presence of a witness, who should, if practicable, be a profes- 
sional brother. The autopsic findings should be dictated at once to an 
amanuensis, and the record verified and signed upon its completion. 

The obducent should have an opportunity to view and examine 
the body before it is taken away from the place or position in which 
it is found, and especially before the clothes are removed. He should 
prior to the autopsy be put in possession of information as to the 

26 



POST MORTEM EXAMINATIONS 

eral, and also any special, circumstances of the case, and more 
particularly in regard to any injury or violence which the deceased 
may have received. I [e should also be advised as to any known disease 
or other condition which may have contributed to the death. No 
one ought to be allowed to witness the examination out of mere 
curiosity or unless specially authorized. The examination should not 
be commenced unless there is sufficient daylight in prospect to allow 
of the whole inspection being made without artificial light. All meas- 
urements should be accurately determined. Examine carefully the 
contents ^\ the stomach to ascertain the length of time which has 
elapsed since the death occurred. Where the services of the obducent 
are called in by the law, he is freed from the necessity which exists in 
i ordinary cases of obtaining the consent of the relatives of the decedent. 

In general the medicolegal post-mortem examination does not 
differ materially from the pathologic, except that in the former greater 
precautions are necessary in order to avoid sources of error or con- 
fusion, and that the cranial contents are examined before opening 
the large blood-vessels, as signs of congestion disappear after the 

ranee of the aorta and venae cavse. Doubly ligaturing the cesopha- 

al the left of the trachea is a good routine practice, and it should 
always be done in cases of suspected poisoning. The urine collected 
from a cadaver is practically always albuminous. The importance of 
examining the vertebrae in all autopsies cannot be too strongly insisted 
upon, as severe injuries thereof may exhibit no external signs of 
violence while there may be other lesions found on the body which 
might otherwise be erroneously assigned as the cause of death. In 
some cases after a most rigid and painstaking inspection no cause of 
death can he ascertained, but with care and systematic examination 
kes and inaccuracies will be reduced to a minimum. 

In case of suspected poisoning the primae viae should be tied at 
end and removed. I >ouble ligatures should then be applied at the 
junction of the duodenum and the ileum and at the end of the small 
intestine, dividing the viscera into three portions. The contents of the 
Stomach and the intestines should be emptied into separate 

jars. Many poisons are extremely volatile and without great care 
5 of them may be losl and justice defeated. 

h organ should be received in a separate receptacle, and each 
ould be marked, sealed, dated, and deposited where tam- 
pering with it would be impossible. The mouth of the receptacle 



MEDICOLEGAL SUGGESTIONS 403 

should be so large that no injury will be done to the organ in its 
introduction. It is also well to remember that a tissue in its fresh 
state goes into a bottle more readily than it comes out after being 
hardened by the preservative fluid. 

The form oi report used by the writer in medicolegal cases is as 
follows : "I made a post-mortem examination of the body of Walter 
Foster on April 10, 1898, at St. Agnes Hospital. Philadelphia. The 
body was identified by George Bell, 636 Siegel Street, and Michael A. 
Binder, 1847 Sartain Street, both of Philadelphia. I find that death 
was caused by shock and hemorrhage from stab-wound of the heart." 

While acting as coroner's physician I rarely volunteered more than 
this, but waited for the district attorney to ask questions in regard to 
the nature of the wound and as to other facts of interest. By this 
method the jury is not confused by an enormous amount of irrelevant 
testimony, though the expert must be prepared to give, under cross- 
examination by counsel for the defence, the minutest details as to how 
the postmortem was performed. 

It may be remarked that there is a growing tendency to perfect 
and render more scientific the proceedings incident to and growing 
Out of violent deaths. Courts have even appointed a commission of 
physicians to examine into the condition of the plaintiff* in personal 
injury cases. It has been suggested that in postmortems involving 
the question of crime the investigation should be carried on jointly 
by experts representing the State and the defendant; also that the 
question as to the cause of death shall be disassociated from that of 
the guilt or innocence of any particular individual and determined 
by a jury or commission of experts: but this brings us into the realm 
of speculation. We do not now confront such conditions. 

Autopsies ox Infants. — The first question to determine in the 
examination of a babe is, was it born alive? If so, was it a full-term 
or a premature birth? If born dead, how many months of uterine 
gestation caused it to reach its present development, and after attain- 
ing its maximum growth was it carried as a foreign body in the uterus? 

Determination of the Viability of a Child from the Post- 
mortem Appearances. — The reader is advised carefully to read 
Paragraphs 23 and 24 of Virchow's regulations for the perform- 
ance of medicolegal postmortems. (See Chapter XXVII.) To dis- 
cover the ductus arteriosus remove the thymus gland, incise the right 
ventricle along its septum, and extend the incision into the pulmonary 



POST MORTEM K\ A. Ml NATIONS 

artery along the middle portion of its anterior wall. The orifice is 
situated between and beyond the two openings of the right and left 
pulmonary branches. If the duet is open, a sound will readily pass 
into the aorta. It should be remembered that decomposition may 
bullae in the lungs, thai the lungs may be distended by the 
forcible introduction of air in the methods used for artificial resusci- 
tation, and that air may gel into the lungs of the child from emphy- 
sematous conditions affecting the uterus of the mother. 

It* in the hydrostatic test the lungs float on top of the water, they 
have been completely aerated, a strong proof of breathing at or after 
birth; if they float beneath the surface, aeration is incomplete; and 
if they sink, no respiration has occurred. Decomposition of the lung 
tissue may cause it to float. A very valuable sign of the viability 
of the child is the presence of uric acid crystals in the kidneys. 

Rigor mortis does not prove, as has sometimes been asserted, that 
the infant was born alive in the legal acceptation of this phrase. The 
rigidity may be «»f the so-called ante-natal variety; it may even un- 
duly prolong labor by interfering with delivery. 1 

The Lancet of April 26, 1902, raises the query whether the dead 
body does not possess properties akin to radio-activity, and alludes to 
the photographs taken by Vignon and exhibited by him, with the wind- 
• preserved at Turin and traditionally said to be that of Christ, 
which seem to justify the belief that the human body is either radio- 
active or that it gives off vapors which exhibit a similar action to light 
np< ■■ e surfaces. Peroxide of hydrogen may be the main factor 

■•med. .Y-rays of short wave length can be reflected, polarized, 
and refracted, and are transmittible by a metal wire. Ballet has found 
the emission of these rays to be decreased in diseases of the cord, as 
myopathies and neuritis, and increased in diseases of the brain, as hemi- 
■ paraplegias. Certain substances seem to store up 
1 emit them later. The question is whether there are 
not various rays of a similar nature. The conversion of radium into 
helium may also be of importance in this connection. Fluorescence 
and phosphorescence have also been much studied of late, and all these 
phenomena may have an important bearing on the future of pathology. 
An ion contains electrons. The iV-rays increase the brightness of a 

!:. and p' cut bacteria may be used for detecting them. 

1 Lancet, February 14, 1903, p. 460. 



MEDICOLEGAL SUGGESTIONS 4 5 

Sight, taste, smell, and hearing become more acute under their in- 
fluence. Chloroform applied to plants seems to hinder their produc- 
tion. The Comptes-rendus hebd. des seances de V Acad, des sciences, 
1903-4, contains most of the best literature on the A 7 '- rays. 

Period of Intra-uterine Gestation. — In deciding the age or 
period of development of the infant the external evidences of value 
are: (1) Length and weight of the child (for tables of dimensions 
and weights of the new-born see page 358). (2) Conditions of the 
skin and its appendages. In the healthy babe at full term the skin 
is white and covers the body smoothly; woolly hairs are present in 
perceptible numbers only on the shoulders; the hair of the head is 
from two to three centimetres long; the nails are hard and horny, 
extending beyond the ends of the fingers, but not of the toes. (3) 
Condition of the umbilical cord, which at term is fifty centimetres 
in length and is inserted somewhat below the middle of the abdomen, 
falling off by inflammatory demarcation on the fifth or sixth day. 
4 State of the cartilages of the nose and ear, being hard in the 
mature infant. (5) Presence or absence of the membrana pupillaris, 
which disappears after the eighth month. (6) Condition of the 
genitals in both sexes; as descent of the testes begins at the seventh 
month, those of the full-term male should be in the scrotum. The 
female labia are generally found closed. (7) The measurement of the 
fontanels, of the cranium, and of the transverse diameter of the body 
at the shoulders and hips. (8) The size of the centre of ossification 
(Beclard's) in the lower epiphysis of the femur. To view this the 
leg is flexed on the thigh, a transverse incision is made below the 
patella, which is removed, and the femur is then exposed. Thin, 
transverse sections of the cartilage are made until the greatest diameter 
of the centre of ossification, if present, is reached. The centre is 
absent before the thirty-seventh week, and in the child at full term 
has a diameter of from two to three lines, though it may even then be 
absent. If the diameter is more than three lines, the child has very 
likely lived for a time since its birth. (Reese.) The osteochondral 
line is also to be examined for syphilitic changes. (9) With but very 
rare exceptions, a full-term child presents in the inferior maxilla eight 
alveolar compartments completely separated the one from the others. 
1 Vibert.) 

From the internal examination important evidence as to the age 
of the child, and especially as to respiration, is secured. Upon ex- 



jo() POST MORTEM KXAMINATIONS 

iing the abdominal cavity, which is to be done before opening the 
thorax or cranium, the position of the diaphragm in its relation to 
the ribs is immediately noted, as especially urged by Virchow. If 
the lungs ^^ nol contain air or are but partially distended, the 
diaphragm readies to the fourth rib; when the lungs are fully dis- 
tended, the diaphragm is at the fifth or sixth rib on the right and at 
\th rib or intercostal space on the left. 

To facilitate the examination of the umbilical vessels, Nauwerck 

•mmends a division of the usual abdominal incision, shortly before 

thing the navel, into two diverging incisions extending to the 
pubes. The abdomen is opened, and the umbilical vein, made promi- 
nent by traction on the triangular flap, is traced along its course, 
ligated, opened with small scissors, and divided. Turning down the 
dap over the pubes exposes for examination the umbilical arteries to 
either side of the remains of the urachus. (Fig. 154.) 

Criminal Abortion. — Formerly abortion was not legally a 
crime if performed with the consent of the mother prior to the 
viability of the foetus. It was at one time not regarded as murder 
even to take the life of a child at any period of uterine gestation. 
The barbarousness and clanger to society of this view were early 

gnized, both abroad and in this country, and various laws with 
d iff (.-rent penalties attached thereto were enacted making it a criminal 
offence to practise abortion at any period of gestation, unless for the 
express purpose of saving life. (Witthaus and Becker.) 

There- is n< 1 other class of cases so trying to the patience, ingenuity, 
and skill of the pathologist as those of abortion, which is accom- 
plished by numerous methods. Many respectable women expose 
then cold, falls, and douches with the hope of relieving 

themselves of their offspring apparently by accident. Many pills 
and potions are sold to induce a resumption of the menstrual dis- 
charge, and one often finds them on sale in drug-stores of the first 
rank and openly advertised even in the religious press. These nos- 
trum letimes composed of poisons that may cause the death 
The use of instruments, especially the spiral douche 

ertised in so many papers, is a very common method of pro- 
cedure. Indeed, the most successful criminal abortionists operate so 
that, unless through accident, no evidence of the operation is left. 

lally all that can be found is evidence of a recent pregnancy. The 
five £ spontaneous abortion are syphilis, alco- 



MEDICOLEGAL SUGGESTIONS 407 

holism, the infectious fevers, endometritis, and diseases of the placenta, 
as apoplexy. It must be remembered that, while there are generally 
accomplices in abortion, yet in many cases it is self-inflicted. The 
difficulty of distinguishing between the two is almost insuperable. All 
that the obducent can do is to use the utmost care in his examination 
and to note all the circumstances, with a view not only to the convic- 
tion of the guilty abettors, but also to clear, if possible, those unjustly 
accused. 

AYhen violence is done to the child, the nature of the injuries 
must be carefully noted. When violence is done to the uterus, some 
form of infection usually follows. In examination care must be taken 
to exclude the possibility of previous disease of the uterus or adnexa 
as a cause of the infection or possibly as a cause of abortion. In 
former days, when curettage was more used than it is now in the 
treatment of abortion, an additional factor was added, making it diffi- 
cult and often impossible to distinguish dilatations of the os due to 
the instrument producing the abortion and to the passage of the foetus 
from those induced by the introduction of the curette and the sub- 
sequent packing with iodoform gauze. The vital history of the foetus 
should be compared with the physical condition of the mother, the 
history of the sexual life of the parents, specific disease, etc. 

Usual Causes of Death. — In Chapter XXVIII will be found a 
list of all the recognized causes of death, and it is recommended that 
this classification be used by every one in order that uniformity of 
nomenclature may be secured throughout the world. Sudden death 
is usually due to failure of the circulatory apparatus, to cessation of 
respiration, to disturbance of the nervous system, to deficient nutri- 
tion, to poisons either produced within the body or introduced from 
without, or to violence by physical or chemical forces, heat or cold, 
electricity, wounds, missiles, etc. 

Many conditions that have existed a long time may cause sudden 
death by breaking the balance of life. Thus, in chronic nephritis 
uraemia may develop suddenly and cause death after only a very slight 
acute illness. Again, an aneurism may rupture without sudden in- 
crease in the symptoms or any violence, simply by a natural slow 
progress of the lesion. All mortal diseases and many that by them- 
selves do not end fatally may contribute to the causing of sudden death 
as well as to slower dissolution. 

Xo disease causing severe disturbance of heart, kidney, lung, 



POST-MORTEM KXAMINATIONS 

nerve, or digestion can be Ignored in estimating the factors that 
brought ;ih<»ut the death of the patient. Certain maladies of common 
occurrence should be in our minds in making examinations, though 
never so prominently as to prevenl a proper search for other con- 
ditions. Thus, in children think of pneumonia, enteritis, bronchitis, 
meningitis, congenital syphilis and other hereditary diseases, infec- 
tious fevers, malformations, etc.; in young adults, infections, local 
and general, violence, typhoid fever, and tuberculosis; in middle 
life, diseases of the lungs, kidneys, heart, and blood-vessels, hepatic 
and ^astro-intestinal conditions, infections, violence, occupation 
neuroses, pneumonia, tuberculosis, cancer, etc.; in old age, nephritis, 
carcinoma, sarcoma, aneurism, cerebral hemorrhage, embolus, throm- 
bosis, tumor or abscess, arteriosclerosis and obstruction of the coro- 
nary arteries, heart lesions, etc. 

In coroner's cases death very commonly results from heart ex- 
haustion, due, as the case may be, to intrinsic disease, to excitement, 
or to poisons. Care should be taken to determine the cause of this 
exhaustion, whether it was due wholly to heart disease, such as a 
valvular lesion, or to one of the exciting causes. In kidney con- 
ions consider whether death was due to failing heart causing 
\e congestion, to poisons, or to inflammatory congestion, such 
ould be part of an acute nephritis. Ascertain if the oedema of 
the lungs is dependent upon cardiac, renal, or cephalic lesions or 
primarily upon a lung condition principally. 

Violent Death. — When there is doubt as to homicide, all the 
precautions necessary for such cases must be strictly observed. The 
soil of violence, its mode of application, and something of an estimate 
as to the amount, direction, and conditions of application of force can 
usually be made from post-mortem examination. In the inspection 
of wounds the condition of the tissues and the position and direc- 
tion of all lesii ivered are to be very carefully noted, as some- 
times the instrument with which they were inflicted may safely be 
inferred therefrom, and at times the findings will point to the dr- 
ain dcr which the injuries were received. A minute descrip- 
tion of the injuries is absolutely necessary, so that if called upon in 
curt an exact account of them can be given. The amount of con- 
tion, extravasation of fluids, and damage to any vessels 
• he- carefully noted. It is important in gunshot wounds that the 
projectile should be found. About the wound of entrance look for 



PLATE VI 



t 





-> 



■ir~. 



H- V 







PLATE SHOWING COMPARATIVE EFFECTS OF "BLACK" AND "SMOKELESS" 
POWDER CARTRIDGES AT SHORT RAM. I 

I :. 2. 3, and 4 are produced by a revolver (.38 inch) charged with ordinary black powder and 
held in hand. The firing distance is eight inches. The markings were made before the members oi 
the Academy of Surgery of Philadelphia on the evening of Mays. i<f>2. In Fig. 1 the hammer is up; 
Fig. 2, to the left; Fi#. 3, to the rifdit ; Fig. 4, down. Fig. 5, revolver immovably held l>y fixing in a 
vice; bullet-hole in centre of brand; black-powder cartridge. Fig. 6, revolver cartridge oi "smoke- 
■ ler. fir^-d from hand; hammer up ; showing circular powder mark, with little oi no "brand"; 
Fitf. 7, same, hammer flown. (The illustration-, are about one-half natural size.) 



MEDICOLEGAL SUGGESTIONS 4CK) 

powder marks, singeing, and smudge. If the projectile struck a bone, 
a splinter may have been detached and caused injuries not along the 
line of the main wound. The effect of small-arms loaded with smoke- 
less powder has recently been studied by Johnson. 1 Such markings 
are less distinct and more indefinite than in the case of black powder. 
Even at a distance of three inches or less the markings may be so 
indistinct as to be capable of being wiped away from the skin with ease, 
and when the part is covered with clothing no powder marks are 
found nor is the clothing scorched. Herold 2 reports a fatal case 
where a pistol fired at short range left no powder markings of any 
description. Plate VI shows the effects of black and smokeless powder 
at short range. (Brinton. 3 ) Death is frequently due to shock, which 
may result from a blow that leaves no mark visible at the post- 
mortem. This is quite uncommon. Injuries to the head make it 
necessary to estimate the structural and tensile strength of the skull 
in each case. "When a fracture of the skull is found or suspected, the 
skullcap must be cut away with the saw only, not using the chisel. 
Contrecoup must always be considered in hunting for fractures and 
lacerations of blood-vessels. Rawling 4 has recently published an in- 
teresting article on the mechanism of skull fractures and Wadsworth 5 
takes up the question of injuries to the brain. Accidents of various 
sorts may produce most marked and varied deformities, and give rise 
to such interesting medicolegal questions as the following: What was 
the duration of life after the reception of the fatal injuries? Did an 
electric shock immediately kill the person, or, being only stunned, did 
he die from the effects of the fall? Did a woman whose decomposed 
body was found in water, with enough arsenic in her system to kill, die 
from the effects of the poison or from drowning? In a case where a 
man shot his wife and then committed suicide, which one died first? 
Suicide. — Upton, formerly of the Chicago Tribune and an author- 
ity upon suicide in America, says that during the last thirteen years, 
1 89 1 to 1903 inclusive, 77,6 17 suicides (57,317 men; 535 physicians) 
were reported as suicides in the newspapers of this country. That 
the number of suicides, especially among children, is increasing 

''Annals of Surgery, 1904. May. p. 798, and June, p. 1006 

5 Legal Medicine, 1902. 

3 Int. Clinics, Twelfth Series vol. iii, p. 148. 

* Lancet, 1904. April 9, p. 973. and April 16. p. 1034. 

'Proceedings Phila. Path. Soc, February 28, 1901. 



. I0 POST-MORTEM KXAMINATIONS 

throughout the world is undoubted, this being more notable in times 
of financial trouble. Up to the time of the Japanese war, suicide had 
not increased in Russia. Prior to 1894 the larger number of suicides 
themselves; now such poisons as gas and carbolic acid are most 
Frequently employed, arsenic not being used so often as formerly. In 
Chicago in [902 there were 147 cases of self-destruction, 127 of which 
were by carbolic acid. In Philadelphia during the same year there 
were [96 cases, of which 42 were from gunshot wound, 33 from gas 
asphyxiation, 32 from strangulation, and 31 from carbolic acid. Ac- 
cording to Vibert, the order of frequency of suicides in France is 
by hanging, drowning, shooting, illuminating gas, and poison. In 
( Germany a favorite method of committing self-murder in the army 
is to explode a blank cartridge in a rifle, the barrel being previously 
filled with water. 1 In a recent suicide in Philadelphia an insane patient 
at Blockley held a razor in each hand and gashed his throat in both 
directions. I have seen cases where a man cut his wife's throat and 
then his own, thus affording a favorable opportunity of comparing 
the wounds inflicted. Great care must be used in making deductions 
from such examinations, as w r ell as in saying from the inspection of 
an incision whether it was made by a right-handed or a left-handed 
prevent detection ingenious w r ays of hiding the effects 
• <\ p< >is< ins up< >n certain parts are often tried. Thus, potassium bichro- 
mate may be introduced into the stomach inside of figs, a device which 
will prevent injury to the upper intestinal tract. 

During my term of service of nearly three years as Senior Coro- 

's Physician of the City of Philadelphia, I performed, according 
to the official records, 799 postmortems, of which 59 were homicidal. 
It should be remembered that there v^ere two physicians for Phila- 
delphia, and that the Coroner's jury were able in many cases to render 
a verdict without a necropsy being made, practically no accident cases, 
• »m known causes, and no subjects accompanied by letters 
1 a physician stating the probable cause of death undergoing such 

mination. Of persons "found dead" the bodies were too much 

mposed to permit of a proper diagnosis, some of them having 

in the water for months or showing skeletal parts alone. Under 

Bright's disease and uraemia are included some cases of 

holism or of deaths incapable of diagnosis post mortem without 



1 London Times, July 30, 1903. 



MEDICOLEGAL SUGGESTIONS 



411 



Cancer 12 

Childbirth 3 

Cholera infantum 9 

Cholera morbus 5 

Concussion of brain 3 



extended chemic or microscopic study, etc. All the victims of heat- 
stroke, with one exception, appeared to be alcoholics. 

The chief causes of death, arranged alphabetically, were : 

Abortion 2S Heart disease 76 

Abscess of various parts of the body 5 Heat 9 

Alcoholism 45 Hemorrhage from various causes 

Aneurism 24 other than extra-uterine, injuries, 

Apoplexy 28 etc 16 

Appendicitis 7 Inanition 14 

B right's disease and uraemia 84 Injuries, as kick of horse, blows, run 

Burns and scalds 5 over by wagon, etc 16 

Meningitis, tuberculous, and spotted 

fever 6 

Peritonitis from other causes than 

abortion and appendicitis 9 

Poisoning 54 

Convulsions 7 Scarlet fever 4 

Croupous pneumonia 19 Stab wound 8 

Cyanosis 8 Strangulated hernia 4 

Diphtheria, including croup 11 Strangulation 7 

Drowning 50 Stillborn 15 

Electric shock 8 Suffocation 9 

Erysipelas 2 Syphilis 3 

Ether narcosis 2 Tetanus 2 

Extra-uterine hemorrhage 4 Traumatic hemorrhage of the brain. 9 

Found dead 9 Tuberculosis of the lungs 16 

Fracture of skull 27 Typhoid 6 

Fractures, other 3 Miscellaneous 68 

Gunshot wounds 25 Total 799 

The fifty-nine cases of homicide were made up as follows : 

Burns 1 Gunshot 18 

Drowning 2 Knife wound 10 

Injuries, as hemorrhage from frac- Poisoning (illuminating gas 2 and 

ture of the skull from a fall fol- strychnine 1) 3 

lowing a blow, etc 24 Strangulation 1 

The kind of poison used in the fifty-four cases was : 

Aconite 1 Oil of merbane 1 

Ammonia 1 

Arsenic 5 

Carbolic acid 10 

Chloroform I 

Creosote 1 

Cyanide of potassium 1 

Hydrocyanic acid 2 

Illuminating gas 12 

Lead 1 



Opium (acute) 10 

Opium (chronic) 1 

Oxalic acid 1 

Phosphorus 1 

Silver nitrate I 

Stramonium 1 

Strychnine 2 

Sulphuric acid t 



}1J POST-MORTEM EXAMINATIONS 

Cases of poisoning are almost daily being reported from new 
sources, by novel methods of procedure, and from a constantly in- 

sing number of unexpected causes. Thus, in flash-light photog- 
raphy the magnesium oxide and the chlorate of potassium may produce 
on ignition chlorin gas sufficient to inflict bodily harm. 1 A dye, para- 
phenylendiamin, used in (lie preparation of certain furs, may give rise 
to bronchial asthma and skin eruption. The use of thread to remove 
particles of \o(n\ from the teeth may cause arsenical poisoning and 
the picking of the teeth with splinters of matches may give rise to 
phosphorous necrosis. Children playing with "tin" toys and soldiers 
in whose flesh are embedded bullets may suffer from lead poisoning. 

- >nous toxins are often produced in imperfectly cured fish. The 
spraying of fruit trees may occasion fatal poisoning by the material 
falling on vegetables below, such as salads and beet greens. Loffler 
calls attention to poisoning by milk from cows that have eaten poi- 
sonous plants. Petroleum sprees, like the old-time chloroform parties, 
are increasing, boys sometimes stealing kerosene from the public streets 
for the purpose. Women smoke ''tea" cigarettes and boys suck the 
cologne from automatic machines. The effects of poisons may be 
modified in many ways; thus, the presence of insoluble substances 
may inhibit to a certain extent their toxic action. 

Burns and Scalds. — Burns are produced by dry heat and show 
when fresh no maceration of the tissues. When inflicted by intense 
heat or by flame, there will be found scorching or singeing of clothing 
and hair, and possibly of flesh. When resulting from contact with a 
hot surface, note especially the shape of the burn, and, if the supposed 
In it object is to be obtained, a corresponding mark may be found 
upon it. In burning the hair often reddens. In burns from electricity 
the markings are apt to be branched. It must not be forgotten that 
burns and scalds, especially when preceded by an explosion, may cause 
considerable injury or even destruction of the parts. Scalds are pro- 
duced by vapor, steam, or a liquid, and usually show some trace of the 
action of the fluid on the mucous membrane or skin. In plain scalds 
singeing is absent, but where fire has followed an explosion both scalds 
and burns may be found. In such cases the mucous membrane of the 
air-pi hould always be examined. In cases of scalds and burns 

the extent of the injuries must be determined both in breadth and in 

'• ut. med. Wchnschr., March 13, 1902, p. 191. 



MEDICOLEGAL SUGGESTIONS 413 

depth, with a careful observation of secondary changes, such as sepsis, 
internal congestions, and inflammations. There are probably produced 
by these means hemolysins and hsemoagglutinins, 1 which products are 
poisonous to the organism, and act as in other forms of auto-intoxi- 
cation. 

Death by Electricity. — There are no absolute and constant 
indications. In some cases the point of entrance or of exit can easily 
be made out by the change in tissues or in clothes. Frequently there 
is marked burning of the skin. In many instances the only evidence 
is an unnatural rigidity of the muscles, sometimes with distortion, due 
to a coagulation of the muscle substance by the current, which, if found 
in one part and not in another of the same body, may be of signifi- 
cance. There may be evidence of electrolytic action in the blood and 
organs, as in the brain and cord. There may be livid areas, even hemor- 
rhages, though after sudden death they are not usual. 

The face is sometimes distorted. The heart is usually flaccid, 
although the left side may be hard or tense. On the right side dark 
fluid blood is often found distending both auricle and ventricle. The 
same condition exists in the left auricle, but the ventricle is almost 
empty- The pupils are invariably widely dilated immediately after 
death. The blood is usually fluid, but clots have been found in the 
heart and large veins. 

Jellinek 2 finds that the anatomic changes in the tissues resulting 
from the passage of a powerful electric current diminish the resistance 
of future currents. Mice are killed with a weak current, but pigs show 
the greatest resistance. Death by electricity occurs more quickly after 
administration of morphine or cocaine, but is retarded by chloroform 
anaesthesia. A dose of morphine might therefore be administered with 
benefit before an electrocution. Microscopically, degenerations are 
found in the gray matter of the spinal cord along with dilatation of the 
central canal and hemorrhages. 

I know of ik; case where it has been alleged that death was due 
to the X-rays. The Galway case, tried in the Dublin courts in March, 
1904. contains the best account on record of the legal liabilities, the 
case being decided for the defendants that the burn was not caused by 



1 Editorial, Jr. Amer. Med. Assoc, January 9, 1904, p. 103. 

2 Wiener klin. Wchnschr., 1902, nos. 16, p. 405, and 17, p. 446. Sec also BoiS, 
Arch, d'electric. vied., Bordeaux, 1903, xi, p. 608. 



POST MORTEM KXAMINATIONS 

negligence. Schonberg lias shown that all the male rabbits and guinea 
to the Rontgen rays proved sterile afterwards. 
in from Heat OR Cold. — After fatal heat-stroke the body 

iften very hoi for hours and decomposition may be uncommonly 
rapid. There may be general internal congestion. It is usually 
necessary to know somewhat of the history of the case before a 
verdict can be rendered of heat-exhaustion, sunstroke, or thermic 
Fever. In cases of death from cold we often find pallor or discoloration 
of the skin and congestion of the viscera with blood of rather bright 
color. No single characteristic lesion results from exposure to 
moderate excess of either heat or cold. When no pathologic lesions 
be found, death is probably due to shock. Any chronic disease 

\ iscera tends to reduce the power to resist severe temperature 
changes. There is no significance in the freezing of the body beyond 
showing that considerable time may have elapsed since death. The 
frozen flesh of the mastodon sometimes found in the Siberian plains 
is good eating, though it must be thousands of years old. 

There are no characteristic changes in sunstroke. Rigor mortis 
comes on early. Lividity and putrefactive changes develop rapidly after 
and even before death. Venous engorgement is extreme, particularly 
in the cerebrum. The left ventricle of the heart is contracted ; the right 
is dilated and may be full of blood imperfectly coagulated and deficient 
in oxygen. The blood is fluid, dark in color, acid in reaction, and prob- 
ably contains, as in burns, a poisonous substance which acts on the more 
highly specialized cells of the body. Petechial patches may appear in 
the subcutaneous and subserous tissues. The elevation of temperature 
ten remarkable, and it is extremely disagreeable to make an autopsy 
in these cases, as I have done, soon after death, with a temperature of 
Io6 c F. In a case of mine of stramonium poisoning, with a tempera- 
ture of nearly i io° F., the clinician had diagnosed sunstroke. 

Infanticide. — Many methods have been resorted to, as exposure 
to cold, smothering in various ways, strangulation either by the hands 
"r by a ligature around the neck, and wounding with various instru- 
ments, sometimes accompanied by efforts to conceal the act. The 
child may be intentionally drowned in a vessel containing fluids 
discharged from the vagina at the time of birth. Gross violence or 
may be employed. 

Death by Starvation. — There is usually extreme emaciation, 
which is shown especially by a sinking of the eyes and an unfilled 






MEDICOLEGAL SUGGESTIONS 41 - 

condition of the skin. It is sometimes necessary to determine whether 
starvation resulted from disease or neglect, especially in cases of those 
children which have been reared in foundling homes and hospitals. 

Suffocation; Strangulation; Hanging; Drowning. — All 
these produce death by asphyxia, or carbon-dioxid poisoning, com- 
bined with oxygen starvation, the signs of which are more or less 
marked. In death from asphyxia there are usually hemorrhages 
into the thymus gland, as well as Tardieu ecchymoses in the pleura 
and pericardium. 

Plain suffocation may show no marks of violence. The dark- 
fluid blood, possibly hemorrhages from increased blood pressure, gen- 
eral congestion of the lungs, frequently congestion of viscera, often blue 
nails and lips, occasionally suffusion of the face with dark venous 
blood, and an absence of other pathologic conditions, give a general 
type of finding that is not easily mistaken when clearly marked but 
is difficult to recognize when not conspicuous. 

Strangulation adds the factor of mechanical arrest of respiration. 
and may result from the presence of food, some foreign substance, 
or a growth or swelling in the throat. When due to throttling the 
marks about the neck are of great importance. There may be com- 
pression of veins. 

Hanging may cause death by injury to the spinal cord as well as 
by compression of the blood-vessels and air-passages. The parch- 
ment-like appearance of the skin on the sides of the neck and the 
rupture of the intima of the carotids afford valuable evidence. 

Wachholz l has shown experimentally that in acute suffocation there 
may be found, along with the soft currant-jelly clots in the heart, solid 
white clots embedded in the meshes of the cardiac muscle. La Cas- 
sagne and Martin have described a method, called docimasie hepatiquc, 
of diagnosing sudden death by a marked increase in the sugar contents 
of the liver of persons who have died suddenly. Wachholz finds from 
his experiments that no such relation exists. 

Reuter, working with Kolisko, 2 from a study of twenty-two cases 
of throttling and two hundred cases of hanging, thinks that these two 
very similar modes of death may be differentiated from each other. In 
throttling there is (i) cyanosis of the face, with ecchymoses of the 



1 Vrtljschr. f. gerichtl. Med., 1902, p. 34. 

2 Zcitschr. f. Heilk., 1901, vol. xxii, p. 145. 



||() POST-MORTEM EXAMINATIONS 

ds and conjunctiva. (2) The seal]), the coverings of the brain, and 

lembranes arc always rich in blood. (3) As a rule, hemorrhages 

in the soft tissues of the neck, especially in the muscles, occur. (4) 

There is marked injection of the upper air-passages, combined with 

numerous small hemorrhages. (5) Injuries to the larynx and hyoid are 

• 1 Rupture of the intima of the carotid is never noted; in only 

three cases were there suffusions into the adventitia. In hanging (1) 

cyanosis o\ the face is usually not noted ; ecchymoses are seen in twenty 

per cent, of typical and in thirty per cent, of atypical strangulations. 

The amount of blood contained in the organs in the skull varies, 

but usually consists only of that which was present in these parts at the 

time the circulation was interrupted. (3) Hemorrhages in the muscles 

are rare, — two per cent, in typical and fourteen per cent, in atypical 

is. (4) Injuries to the laryngeal and hyoid structures are com- 
mon, — sixty per cent, in typical and thirty per cent, in atypical cases. 
Rupture of the intima of the carotids occurs in five per cent, of 
typical and four per cent, of atypical hangings. The external markings 
1 >n the neck are also often different. 

In a case of drowning water or foreign substances may be found 
in the openings of the body, in the respiratory organs, or in the 
stomach, or death may be due to spasmodic arrest of respiration. The 
froth from the air-passages is coarser than that seen in cases of 
< edema. Very soon after death we often find watery fluid in the pleura. 
'Hie spongy condition of the lungs is found only where there has 

1 inhalation of water, which does not always happen. After 

omposition has set in, the evidence of drowning gradually dis- 
appear^ until it is impossible to make the diagnosis. In drowning the 
bleaching of the palmar and plantar skin surfaces occurs very early. 
Littlejohn 1 discusses the differences in appearance after drowning 
in salt and in fresh water. Of those drowned in sea water the soft 
parts are rapidly destroyed by crabs and fishes, in some cases the bones 
alone remaining after ten days, while the body undergoes putrefactive 
changes more slowly. He reports a case where calcium phosphate 
studded the pleura. The place in which a person is drowned 
may sometimes be told by the character of the material found in the 
smaller bronchi. Revenstorf 2 determines the freezing-point of the 



1 Edinburgh Med. Jr., February, 1903, p. 123. 
' Munch, vied. Wchnschr., 1902, no. 45, p. 1880. 



MEDICOLEGAL SUGGESTIONS 41 y 

blood from both sides of the heart, as more or less of the fluid in which 
an animal is drowned usually passes through the capillaries of the lungs 
and dilutes the venous blood. He concludes that the method, when 
positive, — i.e., when it can be shown that the freezing-point of the 
blood from the right side of the heart is higher than that of the blood 
from the left side, — is valuable as additional evidence of drowning, 
and is very easily carried out ; but decomposition rapidly removes any 
difference which may have existed, and the blood is not necessarily 
diluted during death by drowning. 

Cytology. — The different kinds of cells found under various con- 
ditions in the serous cavities form a most inviting field of study. 
Thus, in syphilitic hydrocele we have endothelium, in gonorrhceal 
hydrocele, marked polymorphonuclear leukocytosis, in tuberculous 
hydrocele, lymphocytosis, in mechanical hydrocele, few or no leuko- 
cytes. Naturally, the age of the process has much to do with the num- 
ber and variety of the cells. 

Semex. 1 — The Florence test should be first applied, a reaction 
common to all semen, and then the material studied microscopically. 
Seminal stains remain intact for years under favorable circumstances 
and give the biologic blood test. 

Schiitze 2 finds in the use of the precipitin method of discovering 
spermatozoa that the animal need not be inoculated with semen or 
testicular cells, but that any albuminous fluid of the animal's semen to 
be proved will produce a serum capable of giving rise to the reaction. 

Toxicology. 3 — The presence of poisons in the animal economy 
may be recognized clinically, chemically, pharmacologically, and 
pathologically. While we have chiefly to do with the latter method, 
the success of the chemist and the pharmacologist depends largely 
upon the procedures adopted for the preservation of material by the 
pathologist at the time of the performance of the autopsy. There 
are certain poisons which may kill without leaving in the tissues any 
specific alterations to be found post mortem, especially when the 
examination is postponed for several days. 

A poison is any substance which, when taken into the system and 



1 See Simon's Clinical Diagnosis, T904, p. 664, or any other receni work for the 
method of applying this 

2 Zeitsch. f. Hyg. u. Infcctionskrank., jooi, voh xxxvi, p. 5. 

2 Much of the material in this section is taken from Koiwrt's Lehrbuch tier 
Intoxikationcn, Stuttgart, 1902, and Gi.aister's Medical Jurisprudence, 1903. 

27 



}lS POST-MORTEM EXAMINATIONS 

either being absorbed or by its direct chemic action upon the parts 
with which in contact, or when applied externally and entering the 
circulation, is capable of producing deleterious results. (Wormley.) 
>ning commonly results from alcohol, morphine, lead, arsenic, 
phosphorus, oxalic acid, carbolic acid, etc.; from food (bromatotoxis- 
mus ) : from meat < kreotoxismus) ; from milk products (galactotoxis- 
mus) ; from fish and shell-fish (ichthyotoxismus, mytilotoxismus) ; 
and from grain ( sitotoxismus) ; of the latter poisoning there are three 
kinds. — ergotism, lathyrism, and pellagra. 

It should always be remembered that conditions which we are 
apt to regard as being alone produced by strictly pathologic processes 
are often due to poisons. Thus, toxic inanition may be produced by 
chronic poisoning with mercury, lead, arsenic, etc.; fatty degenera- 
tion, by phosphorus, alcohol, Amanita phalloides, etc.; calcification 
of the renal epithelium, by corrosive sublimate; and amyloid degenera- 
tion, by repeated injections of turpentine. 

Suspicious undissolved foreign bodies may be found in the vomit 
and in the contents of the alimentary tract, as arsenic (white, metallic, 
and various salts), antimony, sulphide of antimony, mercury and its 
preparations, as calomel, oxid, and bichlorid, chrome salts, oxalates, 
cantharides, nux vomica beans, heads of matches, and parts of poison- 
plants. In one of my cases diagnosed as a heat-stroke, with a 
temperature of over uo° F., the finding of leaves of Datura stra- 
monium in the stomach led to the correct diagnosis. Morphine even 
when given hypodermically may be found in the stomach contents. 
Certain chemicals may be detected by odors coming from the body or 
from the various cavities when opened, as alcohol, ether, chloroform, 
formalin, phosphorus, turpentine, nitrobenzol, benzene, 
I alcohol, hydrocyanic acid, paraldehyde, camphor, chloral, car- 
bolic acid, nicotine, bromin, chlorin, iodin, ammonia, hydrochloric acid, 

m. sulphuretted hydrogen, etc. (See also p. 21.) 

When the acidity or alkalinity of the gastric contents is abnor- 
mally increased, certain reagents are to be suspected, such as acids, 
alkalies, and potassium cyanid. The liver especially shows poisoning 
by phosphorus, antimony, arsenic, and toxins, while the kidney is 
affected by haemolytic and methsemoglobinic poisons, by oxalic acid, 
:ury, silver salts, preparations of cantharides, etc. The 
sped [ the blood should always be obtained as soon 

r death or removal from the body as possible. The addition of 



MEDICOLEGAL SUGGESTIONS 4IO/ 

a little distilled water is admissible in methemoglobinemia, but even 
here it is better at once to seal hermetically in glass tubes with exclu- 
sion of air as far as practicable. If the blood coming from veins is 
fluid and scarlet, suspect carbon monoxid poisoning; if a laky purple 
fluid, not changing on the exposure to oxygen, suspect cyanid. If 
the muscles of the abdominal walls are drawn and contracted spirally, 
we may suspect any of the instant poisons, as strychnine or potassium 
cyanid. I have for a long time had a bottle of blood from a case of 
cyanid poisoning, and have many times exposed it to the air by re- 
moving the cork, yet it is apparently still in a perfect state of preser- 
vation. 

The left heart is found markedly contracted in death from over- 
doses of members of the digitalis group, veratrine, and barium salts. 
As already stated, the odor of the poison may sometimes be detected 
on exposing the brain. In one of my cases of ammonia poisoning a 
rod dipped in hydrochloric acid gave off fumes when introduced into 
the cranial cavity after removal of the brain. Much attention has 
been paid to the actions of poisons on the central nervous system, 
and the rapid diagnosis of hydrophobia by this method should not be 
forgotten. For a description of the Negri bodies in hydrophobia, see 
the Zeitschrift f. Hyg. u. Infectionskrank., 1903, vol. xliv, p. 519. 
The joints are alleged to be inflamed after poisoning by colchicum. 
Testicular atrophy is said to be induced by the long-continued use of 
capsicum, solanus pseudocapsicum, and conium maculatum. 

The mucous membrane of the stomach is irritated and stained by 
many poisons, as sulphuric acid (black), nitric acid (yellow), oxalic 
acid (white), bromin (red), iodin (purple), and by a large number 
of metallic salts, as sulphid of arsenic (yellow), chromate of potas- 
sium (red), etc. I have, however, seen several cases of arsenical 
poisoning with but little inflammation of the gastric mucosa. 

Among the questions to be answered in every case of suspected 
poisoning are: Was death caused by a poison originating within or 
without the body? What poison caused death? Is the substance 
found by the chemist the poison which killed the person in whose body 
it was found? Might not the poison have been administered as a 
medicine? Is the poison present in such quantity as always causes 
deatli? Were there attendant circumstances which conduced to the 
fatal result? Was more than one poison given? How and when 
was the toxic substance administered? Could poison have been given 



}JO TOST MORTEM EXAMINATIONS 

and vet not be discovered? Was the fatal dose taken for purposes of 
suicide? Was it administered with the object of killing? Was it ad- 
ministered accidentally? Did the person for whom it was intended 
receive the poison? Could the toxic symptoms be simulated? Was 
cremation practised in order to destroy evidences of poisoning? Was 
there any motive for homicide? Are there any accomplices? What 
became of the vehicle in which the poison was administered? Was 
there any poison found ? Was any poison destroyed ? 

In ease of poisoning the district attorney must prove three things, 
in order to convict of murder in the first degree: first, that the person 
is dead ; second, that death was caused by the poison under considera- 
tion; and, third, that the party or parties on trial administered the 
drug with felonious intent. 

On request of ex-Judge Stevenson, the lawyer for the defence, 
in the case of the Commonwealth of Pennsylvania vs. John and Emma 
Williams, Judge McMichael issued the following order, under which 
I made a post-mortem examination of the bodies of the three children, 
after the experts for the Commonwealth had already made an original 
examination and two disinterments. 

" And now, to wit, this sixteenth day of February, A. D. 1903, it is ordered and 
directed that the defendants through their experts shall have access to the bottles and 
prescriptions taken from 1135 Vienna Street, and also that they shall be permitted to 
exhume the bodies of Anna, Josephine, and Laura Williams, and to make such ex- 
amination as they shall deem necessary and proper, and to remove such portions of 
said bodies as may be necessary to a proper and adequate chemical examination and 
analysis to determine the causes of death. It being understood, however, that the 
Commonwealth shall during these investigations be represented by an expert that 
they may select." 

Nearly every toxicologist has his own classification of poisons. 
Thus, one divides them into mineral, vegetable, animal, and mechanical 
groups, another into irritants, narcotics, and narcotic irritants, a third 
into chemical and vital poisons, etc. All such divisions are arbitrary, 
as quickly becomes evident on attempting to place the various poisons 
in their proper subclasses. 

HEME FOR THE DIVISION OF POISONS. 



LG ANN 



[rrespirable gases : carbon monoxid, coal gas, chlorin, bromin, 

hydrofluoric acid, sulphur dioxid, etc. 
Chemic : sodium hydrate, sulphuric acid, etc. 
Irritant : arsenic, antimony, mercury, phosphorus, etc. 



MEDICOLEGAL SUGGESTIONS 



421 



SCHEME FOR THE DIVISION OF POISONS.— ( Continued. ) 

Irrespirable gases : chloroform, ether, formalin, etc. 
Chemic : carbolic acid, acetic acid, pyrogallic acid, etc. 



Organic 



Irritant 



Alkaloidal 



Synthetical 



I Tox 



Vegetable : gamboge, colchicum, squill, etc. 

Animal : cantharides, etc. 

Narcotic : opium, hyoscyamus, belladonna, 

nabis indica, etc. 
Sedative : digitalis, hydrocyanic acid, acor 

conium, etc. 
Excitomotor : strychnine, ergot, etc. 
Antiseptics : creolin, lysol, etc. 
Antipyretics : antipyrin, acetanilid, etc. 
Hypnotics : sulphonal, trional. 
Bacterial : toxins, hemolysins, cytolysins. 
Animal : snakes, scorpions, ptomaines, etc. 
Vegetable : ricine, abrine, etc. 



SYMPTOMS OBSERVED AFTER THE ADMINISTRATION OF THE 
MORE COMMON POISONS. 1 



Acute Symptoms : 
Death within a few seconds or min- 
utes. 
Deep coma. 



3. Collapse. 



4. Feverish rise of temperature. 



Mania ; furious 
excitement. 



delirium; psychic 



Mental disturbances of the most di- 
verse kind. 



Violent ; 
sions. 



at times, tetanic convu 



1- 



Think of : 

Hydrocyanic acid ; potassium cyanid ; 
carbonic acid ; carbolic acid. 

Alcohol ; morphine ; opium ; chloral 
hydrate and its derivatives; sulpho- 
nal ; chloroform and its derivatives ; 
carbon monoxid ; anilin oil ; oxybu- 
tyric acid. 

Corrosive acids ; corrosive alkalies ; 
nicotine ; arsenic ; antimony ; col- 
chicine. 

Phosphorus ; cocaine ; under certain 
circumstances any of the powerful 
convulsive remedies ; enzymes. 

Chronic alcoholism ; atropine ; canna- 
binone ; camphor ; physostigmine ; 
veratrine; lead (in animals). 

Alcoholism; morphinism; cocainism ; 
pellagra; ergotism; inhalation of 
ether; saturnism; mercurialism ; 
poisoning by bromid ; iodoform ; car- 
bon bisulphid. 

Strychnine; toxin of tetanus; salts of 

ammonia; cytisine; cornutine; pic- 

rotoxin; cicutoxin; active principles 

of digitalis; cocaine; santonine; 

nitine; gelsemine; filicic acid. 



*This table and the following one arc from KoBERT's Compendium dcr Toxi- 
kologie, 1903. 



422 



POST-MORTEM EXAMINATIONS 



SYMPTOMS OBSERVED IN 
Acute Symptoms: 
S. General paralysis, for the most part 
ascending, 
ralysis of individual groups of Lead; arsenic; carbon bisulphid. 



CASES OF POISONING. 
Think of: 
Coniine ; curarine ; colchicine. 



muscles. 
io. Dilatation of the pupil. 



II. Contraction of the pupil. 



12. Amaurosis. 



13. Diplopia and ptosis. 

14. Conjunctivitis. 



15. Moist skin. 



16. Skin conspicuously dry, even in a 

warmed bed. Mouth and throat 
parched. 

17. Urticaria or scarlatiniform erythema. 



18. Eczematous eruptions of the skin. 



19. Diffuse dermatitis, with perspiration 

of the hands. 

20. Acne pustules. 

21. Blisters containing clear serum on the 

skin, or even in the mouth. 
lark, dirty discoloration of the skin, 
which is not, however, cyanotic. 



Atropine ; hyoscyamine ; scopolamine ; 
cocaine ; ephedrine ; aconitine ; coni- 
ine ; gelsemine; sausage poisoning. 

Muscarine ; pilocarpine ; nicotine ; are- 
coline ; morphine ; codeine ; opium ; 
physostigmine. 

Quinine ; salicylic preparations ; extract 
of male fern; belladonna; ursemic 
poisoning. 

Sausage and fish poisoning. 
Irritating vapors (sulphurous, hydro- 
chloric, nitric, and osmic acid; nitro- 
gen dioxid; hydrofluoric acid; chlo- 
rin ; bromin ; carbonyl chlorid ; 
ammonia; ethereal oil of mustard; 
croton oil vapor) ; irritating kinds 
of dusts, as root of ipecacuanha, quil- 
laja bark, pepper, chromate, picrate; 
arsenism ; phenylendiamin, chrysaro- 
bin, [formalin]. 

Opium ; morphine ; aconitine ; musca- 
rine ; pilocarpine ; nicotine ; physos- 
tigmine ; lobeline ; antimony. 

Atropine, as well as belladonna, stra- 
monium, and hyoscyamus ; hyoscya- 
mine ; scopolamine ; sausage and fish 
poisoning. 

Atropine ; hyoscyamine ; antipyrin ; 
quinine ; balsam of copaiba ; cubeb- 
ene ; chloral hydrate ; iodin ; mor- 
phine ; and many internal remedies ; 
handling of nettles (urtica). 

Croton oil ; curcas oil ; cardol ; rhus 
toxicodendron ; powdered cinchona 
bark; carbolic acid; tar. 

Anilin colors ; aurantia ; chrysoidin ; 
malachite green ; Bismarck brown ; 
butter yellow ; anilin yellow. - 

Bromid ; arsenical and antimonial prep- 
arations ; powdered ipecacuanha. 

Spanish fly ; ranunculus acris ; ranun- 
culus sceleratus, etc. 

Argyria; mercurialism; saturnism; ar- 
senical melanosis ; bronzed diabetes. 



MEDICOLEGAL SUGGESTIONS 



423 



SYMPTOMS OBSERVED IN CASES OF POISONING. 



Acute Symptoms : 

23. Bluish discoloration of the peripheral 

portions of the body [like those 
seen in Raynaud's disease]. 

24. Cyanosis. 

25. Yellowish-brown discoloration of the 

conjunctiva, alone or in combina- 
tion with that of the skin. 



26. Discoloration primarily of the tongue 
and the mucous membrane of the 
mouth. 



2j. Secondary discoloration of the gums. 



28. Specific odor to the breath. 

29. Coryza. 

30. Salivation. 



31. Metallic cough and aphonia. 

32. CEdema of the glottis. 

33. CEdema of the lungs. 



34. Luminosity of the breath and vom- 

itus. 

35. Increased liver dulness. 

36. Diarrhoea with vomiting. 



Think of : 
Gangrenous ergotism ; carbolism ; phos- 
phorism. 

Nitrobenzol; benzokcll ; anilin; tolui- 
din ; antifebrin ; exalgin. 

Phosphorus ; helvellic acid ; potassium 
chlorate ; nitroglycerin ; sodium ni- 
trite ; amy] nitrite ; pyrogallol ; arsen- 
iuretted hydrogen ; ictrogen [lupin- 
otoxin], in animals. (In picric acid 
and picrates the discoloration is a pure 
yellow.) 

Reddish yellow — chromic acid and the 
bichromates. Yellow — nitric and pic- 
ric acid. Brown — iodin ; bromin. 
Greenish-blue — salts of copper ; 
Schweinfurth-green. Whitish — cor- 
rosive alkalies ; corrosive acids ; cor- 
rosive metallic salts ; carbolic acid. 

Lead ; silver ; mercury ; bismuth. 
[Bring out for diagnostic purposes 
by the direct application of sulphur- 
etted hydrogen gas to the gums.] 

(See pages 21 and 418.) 

Iodin ; bromin. 

Pilocarpine ; muscarine ; arecaline ; 
nicotine ; cornutine ; physostigmine ; 
cytisine ; mercury ; ammonia ; sapo- 
nine [a glucoside contained in Sapo- 
naria officinalis] ; cantharidine ; caus- 
tics. 

Atropine; hyoscyamine; scopolamine; 
sausage poisoning. 

All caustic poisons. 

Morphine ; muscarine ; pilocarpine ; 
ammonia ; nitric acid vapors, etc. ; in- 
halation during the swallowing of sub- 
limate and other corrosive poisons. 

Phosphorus. 

Phosphorus; agaricus bulbosus; poley 

oil ; alcohol. 
Salts of antimony; arsenic; digitaline; 

pilocarpine; nicotine; muscarine; 

colchicine; corrosive poisons; salts 

of copper; zinc salts; colocynthine ; 

emetine; cepli.'cline ; croton oil, etc. 



I- 1 



POST-MORTEM EXAMINATIONS 



SYMPTOMS OBSERVED IN CASES OF POISONING. 



Acute Symptoms : 
. uniting without diarrhoea, 
lie with constipation. 
c with diarrhoea. 

40. Diarrhoea without vomiting-. 

41. Pulse continuously and markedly 

'. ed. 

4_\ Pulse paroxysmally and markedly 

slowed and thread-like. 
43, Pulse first slowed, then irregular, 

lastly accelerated. 



44. Pulse greatly accelerated. 

45. Abortion. 

[2-hour period of good health be- 
tween the poisoning and the ap- 
pearance of the symptoms. 



Think of : 

Apomorphine ; lobeline ; cytisine. 

Lead salts. 

Barium salts. 

Jalap; podophyllotoxin ; croton oil; 
calomel, etc. 

Opium; morphine; muscarine; areca- 
line ; physostigmine ; baryta ; all nar- 
cotics. 

Lead salts, but only during an attack of 
lead colic. 

Digitalis; hellebore; adonis; coronilla; 
cheiranthus ; nerium ; scilla ; rtro- 
phanthus ; convallaria ; pilocarpine ; 
nicotine ; scopolamine. 

Belladonna, hyoscyamus ; atropine. 

Sabina ; thuja; rue; mentha pule- 
gium ; phosphorus ; ergot ; lead. 

Most of the poisonous fungi, but espe- 
cially Amanita phalloides ; also com- 
bined arsenic. 



TABLE OF THE MOST STRIKING CHANGES WHICH TAKE PLACE 
IX THE URINE AFTER THE ADMINISTRATION OF THE MORE 
COMMON POISONS AND MEDICINES. 



Urinary Condition : 

1. Very acid reaction. 

2. Reaction strongly alkaline. 



3. Odor like violets. 

4. Odor like garlic. 

r oi mcthylmercaptan. 
6. Odor of rotten eggs. 

: ammonia. 
8. Achromatic crystals, with acid urine. 
'. epithelial casts. 
How to yellowish-red color. 



Think of: 

Mineral acids ; acid salts of the metals. 

Corrosive alkalies ; alkaline carbonates : 
salts of organic acids, with the excep- 
tion of oxalic acid. 

Oil of turpentine and related ethereal 
oils when employed medicinally. 

Preparations of tellurium when em- 
ployed medicinally. 

Asparagus, sometimes used medici- 
nally in the form of a syrup. 

Cystinuria exists, or the thiosulphate of 
sodium has been taken medicinally in 
large doses. 

Ammoniaemia ; cystitis caused by strong 
bases [and certain bacteria]. 

Oxalic acid; binoxalate of potassium; 
oxamid ; parabanic acid. 

Cantharidine ; potassium cantharidi- 
nate ; virus of scarlet fever. 

Picric acid; picrates. 



/ 



MEDICOLEGAL SUGGESTIONS 



425 



EFFECT OF POISONS UPON THE URINE. 



Urinary Coxditiox : 
11. L'rine icteric brown. 



12. Urine, reddish. 



13. L'rine colored wine-red by haemato- 

porphyrin. 

14. Urine becomes scarlet upon putre- 

faction. 

15. Urine contains albumin and red 

blood-corpuscles. 

16. Urine contains blood pigment in solu- 

tion. 



17. Urine contains methaemoglobin. 



18. Urine contains urobilin. 

19. Urine becomes black-green on expo- 

sure to the air. 

20. Urine is green when voided. 

21. Urine on exposure to the air becomes 

blackish-brown or even pure black. 



22. L'rine reduces Fehling's solution and 
gives off carbon dioxid with yeast. 



23. Urine reduces Fehling's solution, but 
yields with yeast little or no carbon 
dioxid. 



24. L'rine polarizes light to the right. 



25. Urine polarizes light to the left. 

26. Urine contains increased number of 

paired sulphuric acids and dimin- 
ished number of sulphates. 

27. L'rine contains leucin and tyrosin. 



Think of: 
Phosphorus, toluylendiamin ; cephalan- 

thine ; ictrogen. 
Senna leaves ; rhubarb root ; campecia 

wood (logwood); hematoxylin ; 

fuchsin ; pyramidon ; antipyrin. 
Sulphonal ; trional ; tetranol ; lead 

(rarely). 
Santonine ; santonica seeds ; chenopo- 

dium. 
Corrosive poisons of all sorts. 

Arseniuretted hydrogen ; helvella escu- 
lenta (helvellac acid); cyclamine; 
solanine ; and other saponiferous sub- 
stances. 

Potassium chlorate ; sodium nitrite ; 
anryl nitrite ; pyrogallol ; chrysaro- 
bin ; kairin ; quinine. 

Lead. 

Carbolic acid ; cresol ; lysol ; creosote ; 
guaiacol. 

Methylen blue. 

Melanuria, associated with melanotic 
tumors and with haemochromatosis. 
It may be produced artificially by in- 
jections of melanin. 

Phloridzin ; salts of uranium ; curarine ; 
hydrocyanic acid ; atropine ; amyl ni- 
trite ; chromates and bichromates ; 
bichlorid of mercury ; cantharidine. 

Chloral hydrate ; menthol ; thymol ; 
many of the ethereal oils ; carbon 
monoxid ; chloroform ; formic acid 
and formates; free oxalic acid; ben- 
zaldehyd ; morphine. 

Phloridzin ; salts of uranium ; curar- 
ine ; hydrocyanic acid; atropine; 
amyl nitrite; chromates and bichro- 
mates; bichlorid of mercury; can- 
tharidine. 

Chloral hydrate; menthol; thymol; 
many of the ethereal oils. 

Carbolic acid ; cresolj lysol; creosote; 
guaiacol ; kairin ; antifebrin ; anilin ; 
paramidophenol. 

Phosphorus; acute yellow atrophy of 
liver; pellagra. 



426 



POST-MORTEM EXAMINATIONS 



EFFECT OF POISONS UPON THE URINE. 
Urinary Condition: Think of: 

ew drops of the urine will dilate Atropine; hyoscyamine ; scopolamine; 
pupils of a cat's eye. cocaine; tropacocaine. 

29. Few drops of the urine given to a Strychnine; mix vomica. 
5 cause tetanic convulsions. 
Few drops of the urine upon a cul- All combinations of arsenic, with the 
hire of Pcnicillium brevicaule give single exception of triphenylarsin. 
off an odor of garlic. Selenium and tellurium compounds 

give a similar reaction, but different 
odors. 

31. There is sometimes anuria present. Oxalic acid; binoxalate of potassium; 

oxamid ; cantharidine ; bichlorid of 
mercury. 

32. The urine is voided with strangury. Pilocarpine; anilin colors; canthari- 

dine. 

33. The urine is voided with difficulty on Cantharidine; potassium cantharidate ; 

account of priapism. Gyrinus natator. 

Acids. — Poisoning may be produced by mineral and vegetable 
acids, the corrosive action depending largely upon the strength of the 
acid at the time of its introduction into the body. Naturally, those 
parts are most affected which remain longest in contact with the acid. 
The mucous membrane of the lips rarely escapes, and often the skin 
of the lower lip is discolored. The mucous membranes of the mouth, 
oesophagus, and stomach are acted upon, and oedema of the glottis is 
common. The tissues are softened; sometimes there is actual destruc- 
tion followed by necrosis, which may lead to perforation. Around 
these areas of corrosion is a more or less marked hemorrhagic inflam- 
mation. If the acid were diluted, this inflammation is more marked 
and the corrosion less so. The blood in the external veins of the 
stomach is usually black. In all cases where death does not occur 
quickly, changes are seen in the parenchymatous organs, especially the 
kidneys. The color produced by different acids is somewhat charac- 
teristic. In carbolic acid poisoning the oesophagus is of a silver-gray 
color, the stomach is thrown into rugae, and the mucosa is of a rough, 
brownish, cracked appearance. The urine may be dark in color and 
smell strongly of phenol. In poisoning by sulphuric acid the mucous 
membrane of the upper intestinal tract is brownish or even black, due 
to the extraction of water from the tissues and the action of this acid 
<>n the coloring matter of the blood. It is often difficult or impossible 
ay whether perforation occurred during life or after death. While 



MEDICOLEGAL SUGGESTIONS 42 - 

putrefaction may occur in the stomach, other parts of the body may be 
preserved. The effects of hydrochloric acid are similar to those of 
sulphuric acid, but less marked, corrosive action on the skin being 
almost absent. The eschars are white, and the false membrane sloughs 
off, if life persists for some time. If death is delayed for twenty-four 
hours, there is fatty degeneration of the kidneys. The blood may be 
fluid or thickened. Nitric acid imparts to the skin and mucosa a yel- 
lowish tinge, owing to the formation of a xanthoprotein of picric acid. 
The stomach may be perforated. In oxalic acid and oxalate of potas- 
sium poisoning white to grayish corrosion of the upper intestinal tract 
occurs, crystals of oxalates of lime being found in the blood and 
kidneys. Concentrated acetic acid may also cause death. 

Aconite. — In aconite poisoning the physiologic test should always 
be applied. Xo characteristic lesions are found post mortem. 

Alcoholism. — There are no really characteristic lesions. I. Gastro- 
intestinal Tract. — (i) Chronic hypertrophic gastritis may be followed 
by (2) atrophic gastritis with dilatation. (3) Hypertrophic or 
atrophic cirrhosis of the liver. Orth says, " Most drinkers have no 
cirrhosis of the liver, but a fat liver, and many with liver cirrhosis are 
not drinkers of alcohol." II. Vascular System. — ( 1 ) The heart is usu- 
ally enlarged and its muscle often thin, fatty, and friable. (2) The 
blood-vessels are frequently sclerosed, especially those arteries exposed 
to much strain. (3) The venules of the cheek and nose are often dis- 
tended. III. Central and Peripheral Nervous System. — (1) The pia- 
rachnoid is thickened, with wasting of its convolutions. (2) The blood- 
vessels are thickened, tortuous, and may show miliary aneurisms. (3) 
The motor nerves of the muscles are sometimes altered (multiple neu- 
ritis). IV. Genito-urinary Tract. — (1) The kidneys are enlarged, 
cyanotic, and indurated. (2) The bladder is thickened and often shows 
signs of chronic cystitis. 

Alkalies and Caustic Salts. — Alkalies — potash, soda, and 
ammonia — act much the same as acids except that the involved areas 
are brown or black, due to changes in the blood, and less brittle. 
The epithelium is shed in threads and there are ecchymotic folds of the 
mucosa. Capillary bronchitis is common, as the inhalation of am- 
monia causes intense congestion of the respiratory mucous membrane. 
Stricture of the oesophagus often occurs in patients who recover. In 
one of my cases cancer followed at the seat of stricture due to the 
accidental drinking of lye. 



428 



POST-MORTEM EXAMINATIONS 



\\ riMONY.- Poisoning is usually due to tartar emetic. The mu- 
cous membrane from (lie month to the duodenum inclusive is usually 
inflamed, and often ulcerated and covered with stringy mucus. In 
chronic cases there is considerable emaciation; chemic tests will deter- 
mine its true character. Klosowski employed antimony to murder 
three women; on exhumation their bodies were found to be preserved 
to a marked extent. 

Arsenical Poisoning. — This may be: (a) Acute, (b) Subacute. 
(c) Chronic. In acute arsenical poisoning there is generally a marked 

: o-enteritis, which differs in severity according to the amount taken. 
The mucous membranes are intensely swollen, ©edematous, and present 
small emphysematous bullae or diphtheritic exudate. Petechial erup- 
tions may occur in both the stomach and intestines. The contents of the 
stomach are usually of a brownish color. In subacute arsenical poison- 
ing or where large doses have been taken, patches varying in size from 
a dime to a silver dollar, consisting of an opaque white, yellowish, or 
even violet coagulated lymph mixed with arsenous acid and firmly fixed 
to the mucous membrane, with signs of intense inflammation around 
them, may be found in the bowels. White spots of arsenic are some- 
times discovered between the rugae, and fatty degeneration of the intes- 
tinal epithelium and of the viscera is also present. Chronic arsenical 
poisoning is characterized by wide-spread fatty degeneration, affecting 
especially the heart, liver, spleen, and kidneys. Marked changes are 
also found in the voluntary muscles, which show wasting, fatty degen- 
eration, and often cirrhosis. Trophic changes are common, such as 
overgrowth of hair and nails, both of which are harsh and brittle. In 
life the skin is harsh, dry, and frequently shows eruptions. Although 
arsenic is rapidly eliminated from the body, enough usually remains for 
purposes of identification. The urine should always be saved. The 
white material should be examined microscopically for the octahedral 
crystals, and in England for soot and indigo, as the law there requires 
the retailing pharmacist to mix his arsenic previous to selling with 
one or the other of these substances. The cyanide of cacodyl, dis- 
adet, appears to be one of the most poisonous compounds 
known. There are no characteristic lesions post mortem. It is a 
puted question as to whether bodies keep a longer time after death 
in arsenical cases. The manifold ways in which arsenic may acciden- 
tally get into the system and thus cause death should always be remem- 

d. From wall-paper it enters the system as dust and diethylarsin, 



MEDICOLEGAL SUGGESTIONS 4 2 9 

due to the action of various moulds, such as the Penicillium brevicaule. 
These organisms may in turn be used as the means of detecting- arsenic 
by the odor evolved from the presence of minute traces. In England 
there were recently thousands of cases of arsenical poisoning, with 
many deaths, due to the drinking of beer made from glucose contain- 
ing arsenic. The X-rays have been used to determine the presence of 
the crystals in an unopened stomach. Such a picture with the photo- 
micrographs of portions used in making tests forms valuable evi- 
dence when produced in court during the giving of testimony. Gautier. 
a celebrated French chemist, claims, contrary to general belief, that 
arsenic is a normal weighable constituent of the thyroid gland. He 
estimates 1 that one cubic kilometre of sea water contains 3000 kilo- 
grammes of arsenic. The arsenic localizes especially in the ectodermic 
tissues and in the cells in the nature of nuclein and ferments. Rough- 
on-rats, which contains barium, and Paris green are favorite prepara- 
tions for use by would-be suicides. 

Atropine. — Fatal cases of atropine poisoning, either suicidal or 
homicidal, are rare, though accidental poisoning by the Datura stra- 
monium is common. Death is caused by asphyxiation, the symptoms 
resembling those seen in heat-exhaustion. Careful search should be 
made in the stomach for any seeds, leaves, or berries. 

Boric Acid. — A crusade is now going on in the United States 
against the use of boric acid as a preservative for food-stuffs. In one 
of the cases tried in Philadelphia seven and a half grains of boric acid 
were found in a quart of milk. Wiley has made some feeding experi- 
ments on a large scale and finds that the above amount cannot be taken 
fifty days without the production in some cases of unfavorable 
results. Best 2 reports a fatal case of boric aeid poisoning, and adds 
histories of three other cases from the literature on this subject. 

Chloral Hydrate. — Urine should always be preserved for 

chemic examination. Chloral is often taken with other drugs, as 

morphine, and after a debauch; this renders it difficult or even im- 

11 just what effect the chloral actually has had on the 

m. 

Chloroform and Ether Poisoning. — The saying of Tait, that 
the coroner has to do with chloroform death while the physician si 
the death certificate in ether cases, is well known. Fright may have 



1 Bull, dc la soc. chew, de Paris, Januar 

2 Jr. Atner. ' ;• 805. 



POST-MORTEM EXAMINATIONS 

something to do with death in these cases. Signs of asphyxia are usu- 
ally present and the characteristic odor is capable of determination. But 
then the ether may have been given, yet death be due to other causes. 

\ i \ i: 1 \ hsoning.— At postmortem the heart is found in diastole 
and the nerve-centres are said to be congested. Cocaine should be 
tested for before making the diagnosis. 

PER. — The lining walls of the stomach often have a bluish or 
greenish tinge. On the application of ammonia the coloration deepens 
into a darker shade of blue, or the green is converted into this color. 
Tart of the toxic effect of the arsenite of copper is due to the copper. 
There is marked gastro-enteritis, with ulceration, necrosis of the mu- 

. and at times perforation. Brouardel 1 has written an interesting 

ant of this form of poisoning which was used formerly more than 
it is now. Copper sulphate, when added to reservoirs in the propor- 
tion of i to 100,000, will rid the water of algae. The attempt to purify 
drinking water by adding 1 to 1,000,000 must be considered a danger- 
ens experiment, though cupric sulphate will kill typhoid bacilli in 
laboratory experiments when used in this strength. Zinc, tin, and 
barium salts may also cause death in an overdose. 

Ergot' Poisoning. — After death from ergot poisoning the arteries 
are found contracted and the abdominal viscera inflamed. In the 
chronic form the posterior columns of the cord are sclerosed and micro- 
so 'pic sections resemble those characteristic of locomotor ataxia. 

Formaldeiiyd. — Bock 2 reports a case of poisoning by formalin in 
an imbecile twenty-six years of age. From one to three ounces of a 
four per cent, solution were taken. Death occurred thirty-two hours 
later. The stomach was necrotic, dark, tough, and cut like leather. 
Klubciv"' Zorn, 4 and Levison 5 have also reported cases of poisoning by 
formalin. Formic acid will be found in the urine, the secretion of 
which may almost cease. 

1 [ydrocyanic Acid and Cyanid of Potassium Poisoning. — The 
mucous membrane of the stomach is markedly and uniformly injected 
and congested. The odor of bitter almonds is detected at once on open- 
ing the abdomen. It should always be remembered that, if the post- 

1 La mid. mod., September 17, 1902, p. 305. 

/ Wayne Medical Journal Magazine, July, 1899, p. 249. 
* Munch, vied. Wchnschr., October 9, 1900, p. 1416. 
'Ibid., November 13, 1900, p. 1588. 
1 Jr. Amer. Med. Assoc, June 4, 1904. p. 1492. 



MEDICOLEGAL SUGGESTIONS 43 ! 

mortem is not made for thirty-six hours after death, all the hydrocyanic 
acid may be converted into formic acid. The blood is dark and fluid 
and keeps for a long time without undergoing decomposition. 

Illuminating Gas and Carbon Monoxid Poisoning. — These 
two poisons are not quite alike in their action, though the poisonous 
properties of illuminating gas are largely due to the considerable 
amount of carbon monoxid which it contains, especially if of the 
variety known as " water gas." The body may appear quite life-like, 
with even a rosy hue upon the cheeks. After death the blood retains 
its bright cherry-color for some time, seen especially in the brain, and 
when shaken forms a froth of a violet color. All color reactions should 
be studied at once, before giving time for the oxygen of the air to act 
upon the blood. The skin and internal organs, as also the patches of 
post-mortem congestion, are bright red. The lungs are frequently con- 
gested. Carbon-monoxid haemoglobin produces two absorption bands 
near D and E like oxyhemoglobin, the latter, however, being reduced 
by the addition of the sulphid of ammonium. The blood should not be 
taken from the heart for this purpose, but from the smaller vessels in 
the muscles. It is well to remember that the spectroscopic test may 
even be secured several months after death in favorable circumstances. 
To detect a small quantity of carbon monoxid in the air of a room 
fresh normal blood is added to distilled water until the latter is faintly 
tinged; about five cubic centimetres are placed in a flask of some one 
hundred and fifty cubic centimetres' capacity and agitated several 
minutes in the suspected atmosphere; if the noxious gas be present, the 
liquid assumes a rose tint and gives the characteristic spectrum. In 
cases which live a day or so and then die bilateral softening may occur 
in the region of the inner capsule and the caudate and lenticular nuclei. 
The victim may die from a dose of some other poison taken with suicidal 
intent before turning on the gas. 

Iodin Poisoning. — In iodin poisoning the iodin is eliminated by 
the lungs as well as by the urine. 

Lead Poisoning. — In acute lead poisoning there is marked gastro- 
enteritis, and the bowels usually contain a large amount of blackish 
fluid. The kidneys show evidence of acute diffuse nephritis. In chronic 
lead g the distinctive features are a marked fatty degeneration 

affecting the muscles, kidneys, spleen, and liver. There is often marked 
cirrhosis with atrophy of these organs. Arteriosclerosis with hyper- 
trophy of the heart is also marked. Distinct gouty deposits are often 



,,_. POST-MORTEM EXAMINATIONS 

found, particularly about the big toe. The brain is sometimes shrunken 
and dry. the blood-vessels being constricted; or these organs may be 
pale and extremely linn, or pale and cedematous, as in cases of uraemia. 
The small intestines may show areas of extreme contraction. For the 
detection of lead in urine and post-mortem specimens, the reader is 
referred to the Lancet, September 12, 1903, p. 746. 

Mercurial Poisoning. — The mucous membranes of the gastro- 
intestinal tract, especially the small intestine and caecum, show exten- 
desquamation, with hyperemia, ecchymoses, and grayish-white 
eschars. The bowel generally contains large quantities of liquid of a 
yellowish-brown or blood-stained character. The macroscopic appear- 
ances are those of dysentery. In some acute cases decalcification of the 
bones occurs, with a deposit of lime elsewhere in the body, especially 
in the kidneys. The number of mercurial salts is legion, many forming 
with albumin an insoluble albuminate of mercury. Chronic cases of 
poisoning occur, ulcerative stomatitis being one of the chief lesions. 
Sebillotte, -in 1891, collected one hundred and forty-eight cases of 
poisoning from post-partum vaginal douches of bichlorid of mercury. 
1 le expressed his belief that the poison was not absorbed through the 
healthy mucous membrane, but through laceration of tissue due to the 
process of labor. Hamburger, however, has found that potassium 
iodid appeared in the urine in twenty-four hours when tampons of 
cotton saturated with this substance were placed in the healthy vagina, 
and potassium ferrocyanid or salicylic acid in three hours. H. C. 
Wood, Jr., reports a case of poisoning with bloody urine from the use 
of a douche containing 1 to 2000 of the bichlorid of mercury. 1 

Methyl Alcohol. — Blindness or impairment of vision may occur 
not only from the ingestion of wood alcohol, but also from inhalation 
of its fumes, as methyl alcohol seems to have a predilection for the 
retina and the optic nerve. A number of cases of fatal poisoning 
from this source have recently occurred throughout America. These 
have been tabulated by Buller, of Montreal, and Wood, of Chicago. 2 

Nitrobenzol Poisoning. — Besides the odor of the artificial oil of 
bitter almonds, the blood and muscles are of a brownish color and the 
muo >us membrane of the stomach is ecchymotic and injected. The body 
is cyanosed and of a leaden hue. 



' Amer. Med.. December 27, 1902, p. 1006. 

* Jr. Amer. Med. Assoc., October 1, 8, 15, 22, and 29, 1904. 



MEDICOLEGAL SUGGESTIONS 433 

Nutmeg Poisoning. — For a description of this rare but interest- 
ing- form of poisoning-, the reader is referred to Wallace's article in 
Yaug-han's dedication volume of " Contributions to Medical Re- 
search." Grated nutmeg- is used by some as an emmenagogue. 

Opium Poisoxixg. — In acute poisoning there is nothing- to distin- 
guish the condition of the brain from that in other cases of cerebral 
congestion. Extreme passive congestion of the bases of the lungs may 
take place, as in cerebral apoplexy (Osier). Cases of uncomplicated 
chronic poisoning are rare. The most important lesion is fatty degen- 
eration of the heart. The liver may show similar changes. If lauda- 
num has been used, the characteristic odor may be present. I know 
of no drug which is more apt to escape detection at the postmortem 
than morphine, as there are absolutely no characteristic lesions and 
chemic analyses are difficult and at times inaccurate. It seems strange 
that one of the most common and easily accessible poisons is thus so 
hard to detect. The pupillary reaction is of no value after death, and 
the clotting of blood in the right heart is by no means constant. Many, 
if not all, oi the chemic tests for morphine may be simulated by the 
effect of putrefactive bodies. Kippenberger's method is not considered 
reliable by Clift. 1 

Pellagra Poisoxixg. — The lesions found are in the posterior col- 
umns and the crossed pyramidal tract. The cells in the anterior horn 
are deeply pigmented, and pigment is found in the internal organs and 
the skin. The brain presents general wasting; the ventricles are 
somewhat distended and contain an excess of fluid. 

Phosphorus Poisoxixg. — In acute phosphorus poisoning the 
gastro-intestinal tract, especially in the stomach, shows an intense 
degree of inflammation. Hemorrhages are common and the stomach 
may contain grumous feoffee- ground) blood. The mucous mem- 
brane is the seat of numerous ecchymoses as well as more or less exten- 
sive necroses. The skin, the serous membranes, the muscles, and the 
adi] 5 all show numerous small hemorrhages. Hie blood is 

liquid and dark. The skin is jaundiced. The liver, in the early stages 
increased in size, soon — in from ten to fourteen days — U mall 

m one-half to one-third of the normal bulk), the capsule is wrin- 
kled and shrunken, the color is pale yellowish, and on section the organ 
msh patches in the midst of which of deep 

: Jr. Amer. Med. Assoc, April 23, \ 



POST-MORTEM EXAMINATIONS 

congestion. Drops of fat arc seen upon the knife. The kidneys are 
large, their cortex pale, and the medullary portions congested. The 
epithelium often shows marked granular degeneration. As a rule, the 
spleen is not markedly altered. In chronic poisoning by phosphorus 
wide-spread fatty degeneration is the rule. In cases of workers in 
phosphorus having defective teeth, necrosis of the jaw is not uncom- 
mon. It is the yellow phosphorus that is poisonous and not the red 
variety. Bug exterminators often contain phosphorus. The coating 
from the ends of matches is sometimes taken with suicidal intent. 

PlCROTOXlN. — Carel 1 gives the proceedings in three cases of homi- 
cidal poisoning by picrotoxin, derived from the cocculus indicus berries 
added to the liquor of half-drunken men for the purpose of robbery 
after the production of unconsciousness. 

Potassium Chlorate Poisoning. — The blood has the color and 
consistence of chocolate, the oxyhemoglobin having been reduced to 
methcTmoglobin. There is usually a hemorrhagic nephritis, especially 
of the glomeruli. 

Ptomain and Toadstool Poisoning. — Such cases are of especial 
interest to the toxicologist, as the symptoms produced and the lesions 
found at the postmortem are similar to those caused by many alkaloidal 
and irritant poisons, and the possibility of the case under considera- 
tion in a trial being due to one or other of these substances is always 
suggested by the defence. 

Ricin Poisoning. — In dogs the eosinophile cells are increased in 
number. There is no marked positive degeneration of the liver, though 
the organ is congested and areas of necrosis are seen. In the kidneys 
the epithelial cells show degeneration. 2 

Silver Nitrate Poisoning. — I have been fortunate enough to 
see one case of this rare form of poisoning. The darkening of the 
necrosed mucous membrane on exposure to light was the chief diag- 
nostic point. The child had an inspiration pneumonia. 

Snake Poisoning. — After death caused by cobra bite rigor mortis 
occurs as usual. The areolar tissue in the region of the bite is infil- 
trated with a pinkish fluid and the vessels are injected. The blood 
presents no demonstrable change. The veins of the pia mater are 
usually engorged, and the ventricles often contain turbid fluid. The 



' Merck's Archives, July, 1904. 

' Muller, Zicglcr's Beitrdge, vol. xxvii, p. 331. 



MEDICOLEGAL SUGGESTIONS 



435 



lungs are generally congested and the lining of the bronchi injected. 
The appearance of the kidneys varies from normal to one of intense 
congestion. After death following the bite of an Australian snake 
the appearances are much the same as those just described. The blood 
may contain soft coagula, the lungs are sometimes the seat of hemor- 
rhages, and the mucous membranes may be intensely congested and 
hemorrhagic. The central nervous system shows engorgement of the 
blood-vessels. At autopsy, after the bite of a viperine snake, the 
region of the wound is seen to be the seat of intense cedema and extra- 
vasation of blood, and the underlying muscles are frequently disorgan- 
ized and even diffluent from the latter cause. Hemorrhages may also 
be found in any of the organs and along the alimentary tract. The 
kidneys are acutely congested or hemorrhagic. The blood is fluid. 
Snake venom alone is not poisonous, but it takes a serum complement, 
like lecithin, to make it so. (Flexner and Noguchi.) Keyes 1 de- 
scribes a method of preparing a pure crystalline compound of the 
toxin. The use of cryoscopy in this and other forms of poisoning 
may prove of value. 

Strvchxixe Poisoning. — Rigor mortis is intense and persistent 
and the blood is dark and fluid as in asphyxia. Be sure to save the 
urine if any be present; a frog placed in it will have convulsions, even 
if but a small amount of strychnine be present. Marshall 2 reports the 
method of analysis used in a recent case with success. 

Tannin. — This substance, so useful as an antidote in various 
forms of poisoning, may itself produce violent diarrhoea and vomiting. 

1 Berl. klin. Wchnschr., 1903, nos. 42 and 43. 

2 Amer. Med., June 18, 1904. 



CHAPTER XXVII 

ill I : PRUSSIAN REGULATIONS FOR THE PERFORMANCE OF AUTOPSIES 
IN MEDICOLEGAL CASES 

The Prussian regulations governing the performance of postmor- 
tems by the legally appointed officers of the court are of great historic 
interest, as they bear the imprint of Virchow, and, though put in force 
February 13, 1875, are still observed throughout Prussia. These regu- 
lations also form the basis of similar statutes in other German states 
and in many countries throughout the world; indeed they are so well 
defined that it is advisable, though one may chafe under their appar- 
ently unnecessary restrictions, to depart from them only in exceptional 
instances. This is especially the case if the one performing the autopsy 
is a beginner in medicolegal work. 

I. GENERAL CONSIDERATIONS, 

\ 1. According to the present law, an examination of a corpse 

for medicolegal purposes may be made only in the presence of 
making the Autopsy, . , . . . , 1111 

and their Duties a magistrate by two practitioners, one of whom should be a 

state-appointed physician and the other a district surgeon. Upon 

those performing the autopsy devolve the duties of medicolegal experts. If doubt 

should arise in the technical performance of the autopsy, the physician or his deputy 

decides the question under consideration conditionally upon the right of the surgeon 

to state upon the protocol his dissenting opinion. 

5ta> \ 2. The medical officers are permitted to appoint substitutes 

only when legitimately detained from the performance of their 
medicolegal duties. If possible, the deputy chosen is to be a physician who has 
ed his pro physicatu examination. 

rime after Death § 3- As a rule, postmortems should not be performed until 

at which the Post- twenty-four hours after death ; the mere inspection of a corpse, 
mortem is to be however, may be made earlier than this. 

• tned 

I 4. Generally, post-mortem examinations must not be neg- 

I Kamination of lected nor their performance refused by the legally appointed 

physicians because of the presence of decomposition, for even in 

a badly decomposed cadaver abnormalities and injuries to the 

bones may still be detected; many facts of value in the identification of a body 

may be ascertained, such as the color and appearance of the hair, the absence of 

limbs, etc. ; and substances which have entered the body from without may be 

ns well as pregnancy or poisoning proved. On the same grounds, 

when for one reason or another the advisability of disinterring a body is under 

consideration, the physicians are to approve of such exhumation without regard to 

the time which has elapsed since death. 

436 



PRUSSIAN MEDICOLEGAL POSTMORTEMS 437 

k c. The legally appointed physicians are to be careful to have . 

V - „ . & . FF .j- j • j j- • Instruments 

the iollowing instruments in readiness and in good condition: 
from four to six scalpels, of which the two smaller ones are to possess a straight and 
the two larger ones a rounded cutting edge; one razor; two strong cartilage-knives : 
two forceps ; two double hooks ; two pairs of scissors, — the stronger pair should 
have one blade pointed and the other rounded, while the smaller pair should possess 
one probe-pointed and one sharp-pointed blade; one enterotome; one injecting 
nozzle with stopcock ; one coarse and two fine sounds ; one saw ; one chisel and one 
hammer ; one costotome ; six curved needles of different sizes ; one pelvimeter ; a 
one-metre rule divided into centimetres and millimetres; a measuring-glass divided 
into one hundred, fifty, and twenty-five cubic centimetres ; one pair of scales capable 
of weighing up to ten pounds ; one good magnifying-glass ; blue and red litmus 
paper. The cutting instruments must be perfectly sharp. Those performing the 
postmortem are recommended to have ready for use a microscope with two objec- 
tives, so as to be able to magnify at least four hundred diameters, and the required 
instruments, glassware, and reagents necessary for the preparation of microscopical 
slides. 

§ 6. A sufficienth* large, well-lighted room is to be chosen for the 

autopsy, and all possible care is to be taken in the selection of place for the Autopsy 

a suitable place on which to lay the body and in the avoidance and its Lighting 

of all disturbing surroundings. Post-mortem examination by 

artificial light, except where postponement is impracticable, is not allowed; should 

it be done, the reason therefor must be expressly stated in the protocol (2 27). 

\ 7. If the body be frozen, it must be brought into a heated „ _ .. 

1 f • Frozen Bodies 

place and the autopsy postponed until the cadaver has sufficiently 

thawed ; the employment of warm water or other warm articles to hasten the thaw- 
ing process is forbidden. 

§8. If possible, when for any reason the body is moved, espe- 
cially if transported from one place to another, there is to o/"^^^ 10n 
be no excessive pressure made upon any of the individual parts, 
nor any marked departure from the horizontal position of the organs in the larger 
cavities. 

II. TECHNIC OF THE POSTMORTEM. 

\ 9. Those performing the postmortem must hold steadfastly 
to the object in view, which is to make the investigation with 
accuracy and completeness. All important findings must be 
shown to the magistrate by the obducents before they are entered in the protocol. 

\ 10. In those cases in which this appears to be necessary, the Duties of the Obdu- 
examiners are required, as early as feasible before the perform- tcnts in regard to 
ance of the autopsy, to ask the magistrate for permission to visit *\pe^CircttBi- 
the place where the body was found, and they are to ascertain stances connected 
the position in which the body was discovered and be given an with the 1 
opportunity to examine the clothing which the deceased wore umI( ' r Investigation 
at the time of his or her death. As a rule, however, it is sufficient for them to 
await the solicitation of the magistrate to undertake these investigations. They are 
aho obliged to ask for information from the magistrate in regard to any disclosures 
which might be of u-e to them in the performance of the autopsy or in helping 
them to make up their deductions therefrom. 



Medicolegal Aspects 
of the Postmortem 






POST MORTEM i:\.\MlNATIONS 



ii. h: cases in which a doubtful finding is to be quickly 

and definitely .settled,— as, for example, the differentiation be- 

en blood and a fluid which is merely stained with haematin — 

a microscopical examination is to be then and there undertaken. When circum- 

es render this impossible or when difficult microscopical investigations which 

cannot he made at once are required, — as, for example, of certain tissues of the 

tions of such tissue are to be preserved under legal protection and as 

quickly a- possible thereafter to be thoroughly examined. It is to be distinctly stated 

in the report «>t" such findings when the examinations were performed. 

; [2. The postmortem is divided into two main parts: A. Exter- 

s nal examination (inspection). B. Internal examination (sec- 
two main ai\ i>u>u> v r ' 

tion ). 

^ 13. in the external inspection of the body its appearance in 

lli " M genera] and that of its individual parts in particular are to be 

noted. In this general examination of the body the following 

points, in SO far as possible, are to be brought out and recorded. 1. Age; sex; 

development; general condition of nutrition; any signs of previous illnesses, 

. ulcers of the foot; special abnormalities, — e.g., moles, scars, tattoo markings; 

increase or absence of limbs. 2. The signs of death and the changes that have 

already taken place from decomposition. 

Alter removal by washing of any contaminations of the body in the way of 
blood, faces, dirt, etc., record is to be made of the presence or absence of post- 
mortem rigidity: the general color of the skin of the corpse; the kind and degree 
of coloration and discoloration brought about by putrefaction; and the color, 
situation, and extent of any areas of hypostatic congestion, which are to be incised 
ami then carefully examined and described, in order to prevent their being mistaken 
travasations of blood. 
The following particulars are to be considered in the study of the individual 
part-. 1. In unidentified persons, the color and other appearances of the hair 
(head and beard), as well as the color of the eyes. 2. The possible presence of 
go substances in the normal openings of the head, the arrangement of the 
teeth, and the situation and appearance of the tongue. 3. An examination is next 
n» 1..- made of the neck, the breast, the abdomen, the back, the anus, the external 
genitalia, and finally of the limbs. 

If an injury is found in any of these parts, its shape, situation, and direction 
with relation to fixed points of the body are to be described and the length and 
1th of the injury given in the metric system. In solution of continuity of 
1 rule, to be avoided in the external inspection, because after 
the internal examination of the body and of the injured spot the extent of the 
injur apparent. Should the obducents decide that the introduction of 

this procedure is to be done with great care and special 
mention of the reason therefor is to be made in the protocol (£ 27). When wounds 
■ ion of their borders and the adjacent tissues is to be given, 
and imination and description of the lesions in their original con- 

to be enlarged in order that the internal appearance of the 
• and of the bottom may be disclosed. As to wounds and injuries which 
''>' did not originate from, or have any connection with death,— for 

' in the endeavor to restore life, gnawing by animals, and 
like,— a summary description of the findings is sufficient. 



PRUSSIAN MEDICOLEGAL POSTMORTEMS 439 

i 14. In the internal examination the three main cavities of the 
body— the cranial, the thoracic, and the abdominal— are to be Internal Examina- 
opened. Opening of the vertebral column or of the individual considerations 
joints is not to be omitted in cases where important findings 
might be secured thereby. When there is a definite suspicion as to the cause of 
death, the postmortem is to be commenced with that cavity in which the chief 
changes are suspected. Otherwise the head is to be examined first, the thorax 
next, and the abdominal cavity last. 1 The situation of the organs found in each 
of the above-named cavities is first to be determined, then the color and the appear- 
ance of the exposed surfaces. The presence is to be noted of any unusual con- 
tents, such as foreign bodies, gases, fluids, or clots, and in the last two cases 
measured and weighed, and finally each individual organ is to be examined exter- 
nally and internally. 

£ 15. When no injuries are present, the opening of the cranial . , 

.... , Cranial Cavity 

cavity is accomplished by making an incision from one ear to the 
other directly over the skull, after which the skin-flaps are displaced forward and 
backward. (In case injuries are present, they should be as much as possible circum- 
vented by the knife, thus giving rise to a different procedure.) As soon as the 
appearance of the soft parts and the surface of the bony cranium has been described, 
the latter is cut through with a saw by a circular incision, and the section, the inner 
table, and the other appearances of the calvarium are described. The external sur- 
face of the dura mater is next examined, the longitudinal sinus opened, and its 
contents estimated. The dura mater is then to be separated on one side and laid 
back, and the internal surface of the same described, as well as the appearance of the 
exposed pia mater. After this has been done on the opposite side, the brain is to be 
removed in as perfect a condition as possible, and the presence of abnormal contents 
in the skull is to be noted, and the appearance of the dura and pia mater at the base 
and sides of the skull and the condition of the large arteries are to be described. 
After the opening of the transverse sinuses (and, in case reason therefor exists, of 
the remaining sinuses), the size and shape of the brain are noted and an examination 
is made of its individual parts by means of a series of well-ordered incisions. Such 
parts include both cerebral hemispheres, the large ganglia (optic thalamus and 
corpus striatum), the corpora quadrigemina, the cerebellum, the pons Varolii, and 
the medulla oblongata, in the description of which are to be included especially the 
color, the fulness of the vessels, the consistency, and the structure. In addition, the 
tissue and the vessels of the choroid plexus are always to be described. Th< 
and the contents of the different ventricles as well as the appearance and fulm 
the different vascular plexuses in the individual sections of the brain are constantly 
to be kept in mind, and especial note is to be made of the presence of any clotted 
blood outside of the blood-vessels. The dura mater over the ba^c of the skull and 
the sides is then to be removed and the condition of the bones in these r< 
described. 

I 16. When it is required to open the internal portions of the 

. Parotid 

face, to examine the parotid gland, or to inspect the auditory ,-.,„„,.,. 

apparatus, the initial incision extending over the skull is continued 

behind the ear and down the neck, and the skin, for appcar; 



ntopsies "ii ti uid" <m. 



POST MORTEM IX \M1.\.\ riONS 

ath towards the part to be investigated. In this examination special 
tion is to be paid to the condition of the large arteries and veins. 

, 17. The opening of the spinal column (# 14) is usually made 
1 behind, the skin and the subcutaneous fatty tissue being cut 
directly over the spinous processes and the musculature dissected 
from the side oi the latter and from the vertebral arches. During this exam- 
>rj hemorrhages, lacerations, and similar changes, especially fractures of bones, 
to he carefully searched for. Then a chisel, or, if one is at hand, a vertebral 
| rhachiotome) is used for the purpose of separating the spinous processes with 
the adjacent portions of the arches throughout their entire extent. When they are 
the external surface of the dura mater, which is now brought into view, 
.mined. It is next to be carefully opened by means of a longitudinal incision, 
and any abnormal contents, especially fluid or extravasated blood, are to be described, 
the color, appearance, and similar characteristics of posterior portions of the 
pia mater, and by means of a gentle passage of the fingers over the spinal cord its 
consistency is to be determined. Next, on both sides, by means of a 
itudinal incision the nerve-roots are cut through; then with one hand the lower 
end of the spinal cord is carefully grasped, and, after dividing the anterior attach- 
ments one after another, its upper end is finally drawn out of the occipital foramen. 
In all these proceedings special care should be taken not to make pressure on the 
spinal cord or to bend it. When the cord has been removed, the anterior surface 
of the pia mater is to be examined ; next the external appearance of the cord as 
to size and color is to be described, and finally, by a considerable number of trans- 
verse incisions with a sharp and thin knife, the internal appearance of the spinal 
cord, both as to its white and its gray matter, is to be noted. Finally the dura 
mater of the vertebral bodies is to be removed, and they are to be examined in 
order to determine if there have been any hemorrhages, injuries, or changes in the 
bones or in the intervertebral discs. 

i/ 18. The neck and the thoracic and abdominal cavities usually 

'•" and are opened by means of a single long incision from the chin to 
Abdominal Cavities: ,, • « < • . ,, , , » « ~. r 

il Consider*- the publc s y m P h y sls > passing to the left of the navel. Most 
commonly the incision in the abdomen is made deep enough to 
penetrate the abdominal cavity, care being taken to avoid injuring 
the organs contained therein. This is best begun by cutting a small nick in the 
peritoneum, at the same time observing whether any gas or fluid escapes. One 
is introduced into the opening and then another, the abdominal wall is ele- 
vated from the intestine-, and the further opening of the peritoneum is made 
. between the two fingers. The situation, the color, and other appearances of the 
■ he immediately observed, as well as any abnormal contents within 
them, and the condition of the diaphragm is to be determined by palpation of its 
r -urface. 

The examination of the abdominal organs is to be proceeded with at this time 
only where a strong suspicion exists that the cause of death may be found within 
general rule, the thorax is to be opened and inspected 
re any further scrutiny of the abdominal cavity. 

J 10. In opening the thoracic cavity the soft parts of the breast 
are dissected slightly beyond the junction of the osseous and 
cartilaginous portions of the ribs. Next with a strong knife 



PRUSSIAN MEDICOLEGAL POSTMORTEMS 



441 



the cartilages are incised a few millimetres within their attachment to the ribs, 
care being taken to avoid cutting the lungs or the heart. If the cartilages be ossi- 
fied, the ribs are to be separated with a saw or a costotome somewhat beyond the 
cartilaginous junction. The attachments of both clavicles to the sternum arc then 
separated by vertical semicircular sections, and the junction of the first rib, be it 
cartilaginous or ossified, is loosened with the knife or costotome, great care being 
taken to avoid injuring the vessels which lie beneath. The diaphragmatic attach- 
ments along the line of incision are severed close to the false cartilages and the 
ensiform process. The sternum is turned upward and the mediastinum is cut 
through, with careful avoidance of any injury to the pericardium or the large 
blood-vessels. When the sternum has been separated, the condition of the pleural 
cavity is to be determined, especially as to any abnormal contents, which are to be 
measured and their characteristics described ; also the extent and the appearance 
of any portions of the lung which are in view. If any vessels have been injured 
in the removal of the breast-bone, they are to be tied or a sponge is to be placed 
beneath the bleeding points to catch the blood which if it were allowed to enter 
the pleura would later obscure the observation of the parts therein. The condition 
of the mediastinum and especially that of the thymus gland are to be noted, as well 
as the appearance of the large blood-vessels lying outside of the pericardium, which 
are not yet incised. The pericardium is next to be opened and examined and the 
exterior of the heart inspected. Before the heart is incised or removed from the 
body its size, the filling of the coronary vessels and its individual cavities (auricles 
and ventricles), its color, and its consistency (rigor mortis) are to be estimated. 
While the organ is still in its natural position, the ventricles and auricles are to 
be separately opened and the contents of each chamber determined as to their 
amount, coagulation, and appearance, and the dimensions of the auriculoventricular 
openings are to be ascertained by the introduction of two fingers through the auricle. 
The heart is then to be removed from the body and the condition of the arterial 
vessels tested, first by filling them with water and next by incising their walls. 
Finally the color and exact appearance of the heart muscle are to be described. 
In every case wherein it is suspected that extensive changes — e.g., fatty degeneration 
— have occurred in the muscular tissue a microscopical investigation is to be made. 
To this examination belongs that of the large vessels, with the single exception of 
the descending aorta, which is to be examined after the lungs have been excised. 
A minute inspection of the latter is not undertaken until they have been removed 
from the thoracic cavity. During this procedure great care is to be taken to 
avoid tearing or pressing upon the tissues. Should there he any extensive, (Spe- 
cially old, adhesions, these are not to be broken down, but the attached pleura 
at this point is to be excised at the same time. When the lungs have been removed, 
their surface is again to be carefully examined for recent changes, so that nothing 
shall be overlooked, — for example, the commencement of inflammatory exudations; 
then the air contents, color, and consistency of the individual lobes are to be given. 
Finally large, smooth sections are to be made in order to determine the appearance 
of the cut surface and the air, blood, and fluid contents, as well as any solid con- 
tents of the air-vesicles, the condition of the bronchi and the pulmonary arti 
the latter being examined with special care to detect any >r thi 

purpose the air • 'id the large pulmonai 1 with 

jors and their finer ramifications followed out. When the suspicion arises that 
foreign materials are present in the air-] r substance 

nature of which cannot with certainty he determined by tin 
scopical examination is to be made. 



. , POST MORTEM EXAMINATIONS 

The examination of the neck may, according to the nature 
i>i the case, be made cither before or after the opening of the 
thorax or the removal of the lungs. The obducents may also sever the larynx and 
the bronchus before the further inspection of the remaining parts when it seems to 
them especially desirable so to do. as is the case in drowning or hanging. As a 
rule, it is wise first to examine the large vessels and the nerve-trunks, then the 
larynx and trachea, by means of an anterior incision, and note their contents. If 
this observation should appear to be of especial importance, it is to be made before 
the removal of the lungs, which are at the same time to be carefully pressed upon 

e it' any fluid, etc.. arises in the trachea. The larynx, the tongue, the velum 
palati. the pharynx, and the oesophagus are to be removed together; the individual 
parts are to he entirely opened and their contents and especially the mucosa thor- 

ly examined. At the same time the thyroid, the tonsils, the salivary glands, and 
the lymph glands of the neck are to be observed. In every case where injuries of the 
larynx or of the bronchus have been found or important changes therein are sus- 

1. the air-passages are to be opened after their removal from the body and 
they are then to be examined from their posterior aspect. In cases of hanging or 
in suspicious cases of strangulation the carotids are to be opened in order to ascer- 
tain whether or not their inner coats have been injured. This examination is to 
he undertaken while the vessels are still in their natural situation. Finally the condi- 
tion of the cervical vertebrae and of the deep musculature is to be determined. 

| 21. The abdominal cavity and its viscera are now to be critically 
Abdominal Cavity inspected in such order that the removal of one organ does not 
prevent the exact determination of its relations to another. Thus, 
the duodenum and the gall-ducts are to be examined before the scrutiny of the liver. 
A.s a rule, the following order of examination commends itself: I. Omentum. 2. 
Spleen. 3. Kidneys and adrenals. 4. Bladder. 5. Organs of generation: in the 
male, prostate, seminal vesicles, testicles, and penis with the urethra; in the female, 
• varies, Fallopian tubes, uterus, and vagina. 6. Rectum. 7. Duodenum and stomach. 
ill-ducts. 9. Liver. 10. Pancreas. 11. Mesentery. 12. Small intestine. 13. 
Large intestine. 14. The large blood-vessels in front of the vertebral column, whose 
condition as to blood contents is to be ascertained and noted. 

In every case the spleen is examined in regard to its length, 

breadth, and thickness, not while held in the hand, but when 

placed on a solid surface and without pressure by the instrument used in measuring. 

It i- to be divided throughout its entire length, more incisions being made in different 

directions if diseased areas are found. 

Each of the kidneys is to be removed after cutting vertically 
through the peritoneum externally and behind the ascending or 
nding colon, which is shoved back. The capsule is then incised longitudinally 
through its convex border and slowly peeled off, and the exposed surface of the 
kidney i~ examined in regard to size, form, color, condition of blood, and other 
. xt a longitudinal incision is made through the entire kidney to its 
pelvis, and the cut surfaces are washed with water and described, in which descrip- 
tion medullary and cortical substances, vessels, and parenchyma are to be distin- 
hed. 

I he pelvic organs (bladder, rectum, and genitalia connected 

therewith) are removed preferably en masse, the bladder being 

i'd and its contents examined while it is still in its natural 

lation. After their removal these organs are again inspected, the reproductives 



PRUSSIAN MEDICOLEGAL POSTMORTEMS 443 

being examined and opened last. The slitting of the vagina is to precede that of the 

uterus. In puerperal the venous and lymphatic vessels both in the internal surface 

of the uterus and in its walls and adnexa require special attention as to their width 

and contents. 

When their external condition has been determined, the stomach 

... . , . . . , . , . , Stomach and 

and duodenum are with a pair ot scissors opened in their natural Duodenum 

situation, the duodenum on its anterior surface and the stomach 
along its greater curvature. After a careful inspection of their contents, the per- 
meability and the presence of any matter in the opening of the gall-passages are 
determined and these parts are then removed for further examination. 

The liver is first described externally in its natural situation, and , . 

Liver 
after its secretory ducts have been examined (as mentioned in 

the preceding paragraph) the gland is excised. Smooth incisions are now made 
through the entire length of the organ and its capacity for blood and the condition 
of the parenchyma determined. In the description a short account is always to be 
given of the general relations of the individual lobes, noting especially the condition 
of the inner and outer portions. 

The small and large intestines, after their individual portions 
have been examined externally as to dimensions, color, and other Small and Large 
peculiarities worthy of mention, are removed together, their Intestines 
mesenteric attachments being severed with a knife close to the 
bowels, which are then opened with a pair of scissors at the place where the mesen- 
tery was attached. During these incisions the contents of the several parts are 
observed and described. Next the intestines are cleansed and the condition of the 
individual portions, especially of the small intestine, is inspected with special regard 
to the Peyer's patches, the solitary follicles, the villi, and the intestinal folds. At 
least in every case of inflammation of the peritoneum the appendix is to be carefully 
examined. 

\ 22. In those cases in which poisoning is suspected the internal 
examination is to begin with the abdominal cavity. Before any- Cases of Poisoning 
thing else is done the external appearance of the upper abdominal 
viscera, their situation and extent, the filling of their vessels, and the presence of 
any odor are to be determined. In regard to the vessels, here as in other important 
organs, we are to ascertain whether we are dealing with arteries or veins, whether 
only the main trunks and their branches or the smaller ramifications also are filled to 
a given degree, and whether the extent of the vascular thinning is considerable or 
otherwise. Then to the portion of the oesophagus just above its entrance into the 
stomach and to the duodenum just below the entrance of the gall-duct double liga- 
tures are to be applied and both parts incised between them. Next the stomach with 
the duodenum attached is carefully removed from the body and opened in the 
manner described in \ 21. The contents are immediately examined as to theii 
amount, consistency, color, composition, reaction, and odor, and placed in a clean 
porcelain 1 Then the mucosa is washed and its thickness, color, 

ce, and condition are determined, the state of the blood-vessels and the struc 
ture of the mucous membrane being particularly noted and each main portion 
separately described. Of especial importance is it to ascertain whether the blood 
which i^ | within the vessels or is exuded therefrom, whether it i- fresh 

lecomposition or by digestion, and whether in these conditions the 
neighboring rmeated therewith. If such imbibition has occurred, it is 

to be noted whether it is found only upon tl 0, whether 



MORTEM KXAMINATIONS 

ulatcd or not, etc Finally it is of especial importance to decide, in the 
ction of the surface, whether loss of substance, erosions, and ulcers are present 
I'lu- question whether certain changes might not have resulted from natural processes 
composition after death, especially from the action of the fermentative juices 
mach, is always to be considered. After the completion of this examina- 
the stomach and duodenum are to be placed in the same vessel with the gastric 
and given to the magistrate for further investigation. An 
imical examination having been made of the oesophagus, it is tied high up in 
the r.. d above the ligature, and placed in the same vessel. In those cases 

in which but a small amount of stomach contents is present the contents of the 
jejunum arc also to be preserved. Finally other substances and portions of organs, 
as blood, urine, pieces of the liver and of the kidney, etc., are to be removed from 
the body and given to the magistrate for further examination. The urine is to be 
placed in a separate vessel, and the blood is to be preserved separately only in those 
where spectroscopic examination might disclose facts of interest. All of the 
remaining portions are to be placed together in a single receptacle. Each of these 
closed, sealed, and labelled. In every case where the macroscopical ex- 
amination shows special alteration and swelling of the mucous membrane of the 
stomach, a microscopical examination thereof is to be made as soon as possible, 
rial attention being given to the condition of the peptic glands. Whenever 
suspicious bodies are found in the stomach contents, as portions of leaves or other 
parts of plants, remnants of animal food, etc., these also are to be viewed with a 
microscope. Where trichinosis is suspected, not only a microscopical examination 
of the contents of the stomach and of the upper portion of the small intestine is to 
be made, but portions of muscular tissue from the diaphragm, the neck, and the 
thorax are also to be laid aside for future study. 

I 23. In postmortems on the new-born, besides the points pre- 
viously given, there are to be determined, first of all, the data 
ati ™° f ?!? upon which the maturity and the intra-uterine developmental 

Maturity and Tenon . ' r 

..1 intra-uterinc period of the child depend. For these purposes consider the 

length and weight of the body, condition of the general coverings 

and of the umbilical cord, length and appearance of the hair of 

the head, size of the fontanels, longitudinal, transverse, and diagonal measurements 

of the head, appearance of the eyes (pupillary membrane), condition of the nasal 

and auricular cartilage, length and characteristics of the nails, transverse diameter 

of the shoulders and hips; in boys the condition of the testicles and the appearance 

of the scrotum, and in girls any peculiarities of the external genitalia. It still 

ins to be noted whether there be present, and if so to what extent, an ossifying 

centre in the inferior epiphysis of the femur. To determine this the patella is 

.cd through a horizontal incision made just below it while the knee-joint is 

gly flexed, and thin trans verse sections are made continuously through the 

until the greatest transverse diameter of any centres of ossification which 

• ;it is found, which is then to be measured in millimetres. 

When from an examination of the offspring it seems to have been born before the 

thirtieth week, the postmortem may be discontinued unless a special request is given 

te for its completion. 

824. If it be determined that the child was born after the thir- 
tieth week, the following data must be obtained in order to 
decide whether it breathed during or after birth. For this pur- 
lory tests are to be applied in the following order: 
(a) Immediately after the opening of the abdominal cavity the 



The I >< t' rmi nation 



PRUSSIAN MEDICOLEGAL POSTMORTEMS 



445 



condition of the diaphragm in relation to the corresponding ribs is to be determined. 
Hence in every case of examination of the new-born the abdominal cavity is to be 
opened first and afterwards the thoracic and cranial cavities. 1 (b) Before opening 
the thoracic cavity the trachea is to be once ligatured above the sternum, (c) The 
thoracic cavity is next to be opened and the extent and consequent situation of the 
lungs, the latter especially in regard to the pericardium, determined, and also the 
color and consistency, (d) The pericardium is to be incised and both its condition 
and the external appearance of the heart are to be described, (e) The individual 
cavities of the heart must be laid open, their contents noted, and other appearances 
determined. (/") The larynx and the portion of the trachea above the ligature are 
to be slit, and their contents as well as the appearance of their walls determined. 
(g) The trachea is to be cut through above the ligature and removed in connection 
with the other organs of the thorax. (/;) After the removal of the thymus gland and 
the heart, the lungs are to be tested as to whether or not they float in a large vessel 
filled with pure cold water. (i) The lower portion of the bronchus and its branches 
are to be opened and their contents specially examined. (/) Incisions are to be made 
into both lungs, the presence or absence of crepitation being carefully noted as well 
as the amount and appearance of any blood which may exude under slight pressure 
upon the cut surfaces, (k) The lungs are also to be incised under water in order to 
determine if any air-bubbles arise from the cut surfaces. (/) The lobes of both 
lungs are next to be cut apart, each lobe subdivided, and every separate portion tested 
as to its sinking or floating in water, (in) The oesophagus is to be opened and its 
condition ascertained. (n) Finally, in those cases where it is suspected that the 
pulmonary tissues may have been filled with the products of disease (hepatization) 
or with foreign bodies (vernix caseosa and meconium), so as not to permit of the 
entrance of air. the same are to be examined microscopically. 



£ 25. Lastly, it is the duty of the obducents to examine all organs 
not mentioned in these regulations in case injuries or other 
abnormalities are discovered. 



Further 
Examinations 



Closure of the 



? 26. The district surgeon, with the second physician acting as 
a consultant, is required, after the ending of the autopsy and as 
far as possible the removal of waste, to undertake the proper closure of those cavi- 
ties of the body which have been opened. 



III. THE DRAWING UP OF THE PROTOCOL OF THE POSTMORTEM 
AND THE FINAL REPORT OF THE SAME. 

\ 27. A post-mortem protocol is to be made by the magistrate, 

, , . , . ,, ,, 1 he Post-mortem 

at the time and place of performing the autopsy, concerning all j,,.,,,,,,,,, 

matters relating thereto. The medical officer must, therefore. 
be careful that the technical findings which have been determined at the examination 
are faithfully recorded in the protocol. In order to accomplish this, it is recom- 
mended to the magistrate that the description and findings of each individual organ 
be written down before another part is examined. 

1 But i- ■ of thK- organs of the abdominal <a\ Itybe undertaken l>< fore tin- opening 

and examination of those of the thorax. 






POST MORTEM EXAMINATIONS 



, 28. The technical findings given in the post-mortem protocol 

m ent and by the medical officer must be stated clearly, definitely, and in 

tanner .1- to be understood by one who is not a physician; 

for this purpose the use of foreign expressions is to be avoided 

• where these may he needed to make clear the description of the findings. 
The chief divisions, the external and internal examinations, are to be designated 
with capital letters ^.\ and B). The findings for the openings in the cavities are 

given, in the order in which they were examined, with Roman numerals (I., 
II.) ; hut the organs in the thorax and abdominal cavity are to be entered under a 
single number. The descriptions of the organs of the thorax and abdominal cavity, 
named in N iS. arc to he designated by the letters a and b. The results of the 
examination oi each individual part are to be designated with Arabic numerals, 
Mich numbers running consecutively from the beginning to the end of the protocol. 
The record i^i the examination must be given in the protocol with special reference 
to the actual observations, and not in the form of mere statements of opinion, — as, 
for example, inflamed, gangrenous, healthy, normal, wound, ulcer, and the like. The 
obducents have the option, however, in those cases in which it seems necessary for 
clearness, to add such observations, inclosed in parentheses. In every case a note 
must he made of the blood contents of each important part, and a short description 
thereof must he given, and not simply a name, — as considerable, moderate, middling 
amount, much reddened, rich in blood, poor in blood. Before any part is incised its 
•m. color, and consistency are to be noted, in the order here named. 

2 29. At the close of the postmortem the obducents are to give 
Provisional Opinion in the protocol their provisional opinion of the case, without 

stating their reasons therefor. If anything be known by means of 
which the diagnosis is influenced, in the way of previous history or the like, this 
must he briefly noted. Should the magistrate ask any special questions, the answers 
-hould he distinctly entered in the protocol, with the statement that they are given 
at his request In every case the opinion as to the cause of death is to be stated, 
fir- 1 with special reference to the facts bearing on the objective findings and then 
as to the question of criminal motive. If the cause of death is not determined, this 
fact must he recorded. It is never sufficient to say that death resulted from 
internal causes or from disease. The latter, whatever it is, must be specifically 
named. Special mention is to be made, with the reason therefor, in cases where 
further technical examinations are needed or where doubtful conditions exist. 

'{ 30. Should injuries be found on the body which were presuma- 
bly the cause of death, and if suspicion be aroused that a specially 

..Ttir.ns on . . . . 

instruments discovered instrument might have inflicted such injuries, the 

obducents, at the request of the magistrate, are obliged to investi- 
opinion as to whether any and, if so, what injuries might have 
1 by the instrument, and what conclusions from the situation and appear- 
ance of the wound are to he drawn as to the manner in which the one performing the 
act might have committed the deed, and also as to the strength with which it was 
performed. When definite weapons are not found, the obducents, as far as it is 
ible from the conditions present, are to give their opinion as to how the iniuries 
■ d and especially as to what instruments might possibly have been used. 



PRUSSIAN MEDICOLEGAL POSTMORTEMS 



447 



g 31. If the obducents be requested to present a report, this should 
be introduced without useless formalities by a condensed but Post-mortem Report 
exact review of the case, with the conclusion reached by them and 
the facts on which it is based. Then so much of the post-mortem protocol as they 
think necessary for the explanation of the case is to be given verbatim, with the 
number of the protocol. Any change made therein must be expressly stated. The 
style of the post-mortem report must be plain and concise, and the proof which led 
to the formation of the opinion therein expressed so set forth as to be understood by 
and convincing to one not a physician ; for this purpose, the obducents are to use, as 
far as possible, German expressions and ordinarily accepted meanings. Especial 
attention to literary sources of knowledge is, as a rule, to be avoided. When as 
medical experts the obducents are asked certain questions by the magistrate, these 
are to be answered fully and as directly as possible, or, if this cannot be done, the 
reasons therefor are to be given. 

Both obducents must sign their report, which must also bear the official seal of 
the district physician if he has taken part in the autopsy. When such a post-mortem 
account is requested, it must be delivered by the obducents within four weeks at 
the latest. 



CHAPTER XXVIII 
- \i. CAUSES of death; their nomenclature, complications, 

AND SYNONYMS 

morbidity and mortuary statistics are intimately associated 
the one with the other, uniformity in their nomenclature throughout 
the world is greatly to be desired. At the Eighth International Con- 
Hygiene and Demography, held in Paris, August 18 to 21, 
1900, a modification of the old Bertillon classification was adopted and 
called the " International System of Nomenclature of Diseases and 
Causes of Death." 1 It is here added but slightly altered in a few 
minor particulars as to the causes of death. 

I. GENERAL DISEASES. 

1. Typhoid Fever (Abdominal Typhus). Include: Dothienenteritis ; mucous, 
continued, enteric, ataxic, or adynamic fever; abdominal typhus. — Do not 
include: Adynamia (179); ataxo-adynamia (179). — Frequent complications: 
Pneumonia ; pulmonary congestion ; intestinal perforation ; peritonitis ; in- 
testinal hemorrhage, sloughing; albuminuria. 
Ex ANTHEM ATOUS Typhus. 2 Include: Petechial fever; petechial typhus. — Do 
not include: Abdominal typhus ; typhus. 

3. Relapsing Fever. Include: Recurrent fever; recurrent typhus. 

4. Intermittent Fever and Malarial Cachexia. Include: Paludal fever ; per- 

nicious fever ; accesso pernicioso; remittent fever ; malaria; ague; etc. 
4a. Malarial Cachexia. Include: Paludism ; pernicious cachexia; etc. 

Smallpox. Include: Variola, varioloid. — Do not include: Varicella (19). — 
Frequent complications: Meningitis; endocarditis; suppuration; albuminuria. 

6. Measles. Include: Eruption of measles; morbilli. — Do not include: Rubeola 

or German measles (19). — Frequent complications: Bronchitis; broncho- 
pneumonia. 

7. Scarlatina. Include: Puerperal scarlatina; scarlatinous angina. — Frequent 

complications: Albuminuria; eclampsia; oedema of the glottis; hemor- 
rhage; endocarditis; pericarditis; paralysis; convulsions; diphtheria. 
WHOOPING Cough (Pertussis). Frequent complications: Bronchitis; spasms. 
9. Diphtheria and Croup. Include: Diphtheritic, buffy, pseudomembranous, 
infectious, malignant, or toxic angina. Diphtheria under all its forms, espe- 
cially diphtheria of wounds, cutaneous diphtheria; conjunctival diphtheria; 



1 Supplement to Public Health Reports, vol. xv, 110.49. Translated by Passed Assistant Surgeon 
H. I> •'.111.IAM A. KING, Chief statistician of vital statistics of the United States Census, 

this list the indefinite and unsatisfactory synonyms used for causes of death in the returns to 
lSgoand 1900. Washington, 1902. 

* The word "typhus," without qualification, will be taken in the sense which is usual to it in each 

• .— viz.. in thi lominal typhus" in German-speaking countries, or as " exanthematous 

aking ones. 



USUAL CAUSES OF DEATH 



449 



buccal diphtheria ; pseudomembranous bronchitis ; pseudomembranous lar- 
yngitis; malignant laryngitis; diphtheritic paralysis, etc.- — Do not include: 
Stridulous croup (88) ; spasmodic croup (88) ; false croup (88) . — Frequent 
complications: Pneumonia; albuminuria; paralysis. 
9a. Diphtheria. 

io. Influenza. Include: Grippe : grippe pneumonia : grippe bronchitis ; epizootic ; 
and grippe bronchopneumonia. 

ii. Sweating or Miliary Fever. Include: Sudor. 

ij. Asiatic Cholera. Include: Indian cholera; cholera (when epidemic); epi- 
demic cholera. 

13. Cholera Nostras. 1 Include: Sporadic cholera: cholerine; choleriform en- 

teritis or diarrhoea; cholera (when not epidemic). — Do not include: Cholera 
infantum (105 or 106) ; antimonial cholera (175) ; hernial cholera (108). 

14. Dysentery. Include: Choleriform dysentery; Chinese dysentery; dysentery 

of tropical countries. 
14a. Epidemic Dysentery. 

15. Bubonic Plague (Plague or pest). 

16. Yellow Fever. Include: Vomito negro; amarilla fever ; black vomit. 

17. Leprosy. Include-' Elephantiasis Grsecorum. — Do not include: Elephantiasis 

Arabum (143d) ; Morvan's disease (63) ; syringomyelias (63). 

18. Erysipelas. Include: All surgical erysipelas or medical erysipelas, without 

regard to seat; St. Anthony's fire. — It is disputed whether to classify gan- 
grenous or phlegmonous erysipelas here or under 144. 

19. Other Epidemic Affections. 2 Include: Mumps; rubeola; acrodynia; vari- 

cella; beriberi; and any other epidemic affections which may not be in- 
cluded in this nomenclature. — Do not include: Epidemic dysentery (14a) ; 
epidemic cerebrospinal meningitis (61). 

20. Purulent and Septicemic Infection. 3 Include: Pyohaemia ; purulent ab- 

sorption; putrid absorption; putrid infection; putrid fever; anatomic 
(dissection) wounds; streptococchcemia. — Do not include: Puerperal septi- 
caemia (137) ; infectious fever (55). 

21. Glanders and Farcy. 

22. Malignant Pustule. Include: Charbon ; splenic fever. In France as 143. 

23. Rabies. Include: Hydrophobia. — Do not include: Sitiophobia (68). 

24. Actinomycosis, Trichinosis, etc. Include: Dystoma hepaticum; cysticcrci. 

— Do not include: Cyst or hydatid tumor of the liver (in) or of the lungs 
(99); intestinal parasites (107). 

25. Pellagra. 

26. Tuberculosis of the Larynx. Include: Tuberculous laryngitis; laryngeal 

phthisis. 

27. Tuberculosis of the Lungs. 4 Include: Pulmonary tuberculosis ; pulmonary 

phthisis: phthisis (without qualification) ; phymia; phymatosis ; pneumo- 
phymia; acute, galloping, or miliary phthisis or tuberculosis; pulmonary 
cavities; consumption; caseous pneumonia ; tuberculous, bacillary, specific, 

1 The word "cholera morbus" will he taken in its ordinary signification in each country, as in the 
sense of " cholera nostras*' in North America, and as " Asiatic cholera'' in France and in other countries. 
- In cases where epidemics arise, it will here to adopt a special provisional title. 

n a female of childbearing age is returnee or any 

• term, send the report back in order that the physician may state whethei 01 nol th< 
puerperal. 

« See observation on No. 93, relative to "apical pneumonia " 

29 



P( >ST MORTEM EX \.MI.\ \TIONS 

.141. mular. neoplastic, or heteroplastic bronchitis or pneumonia; bacillosis ; 
tuberculous pleurisy; tuberculous haemoptysis; tuberculosis (without quali- 
fication >. Do not include: I hemoptysis (without qualification) (99): 
pulmonary hemorrhage. ( 99 ) ; bronchorrhagia (without qualification) (99); 
apical pneumonia (93); laryngeal phthisis (26); pulmonary anthracosis 
(99). — Frequent complications: Hemorrhage; pneumonia; pleurisy; in- 
controllable diarrhoea. 

!i BERCULOSIS OF THE Meninges. Include: Meningeal tuberculosis; tubercu- 
lous meningitis; granular, miliary, caseous, bacillary, specific, neoplastic or 
heteroplastic meningitis; tuberculous meningitis of spinal cord. — Do not 
include: Meningitis (without qualification), even for children of tender 
(61). 

Abdominal Tuberculosis. Include: Tuberculous, granular, bacillary, or 
specific peritonitis; peritoneal tuberculosis; tuberculous enteritis. 

30. Pott's Disease. Include: Vertebral caries; vertebral polyarthritis. — Frequent 

complications: Cold abscess, or abscess by congestion; paraplegia. 

31. Cold Abscess (Abscess by Congestion). Include: Ossifluent abscess. 

32. White Swelling. Include: Fungous growths of joints; coxalgia ; scapu- 

lalgia; tuberculosis of joint. 

33. Other Tuberculous Affections. Include: Tuberculosis of the skin, eye, 

bone, genital organs, etc.; tuberculous adenitis; lupus; esthiomene ; bacil- 
lary abscess; tuberculous ulcer. — Do not include: Pott's disease (30). 

34. Generalized Tuberculosis. Include: Tuberculosis showing itself simulta- 

neously in any two or more organs. Often better placed under 27. 
35 Scrofula. (An unsatisfactory title.) Include: Struma; King's evil ; lympha- 
tism; scrofulides. — Do not include: Scrofulous or lymphatic keratitis and 
blepharitis (75). 

SYPHILIS. Of which are recognized: (1) Primary, (2) secondary, (3) ter- 
tiary, (4) hereditary. These divisions are intended for mortuary statistics 
alone. Include: (1) Indurated or infecting chancre; chancre of the mouth 
■ ii- face; primary accident or infection; (2) Secondary manifestations — 
mucous plaques ; syphilitic amygdalitis ; angina or laryngitis ; (3) Tertiary 
manifestations — specific manifestations ; gummata; ulcerations; exostoses, 
etc. Osteocopic pains; all these diseases to be specified as "syphilitic." — 
Do not include: Soft, simple, or phagedenic chancre (36a). 

CHANCRE. Include: Chancroid; chancrelle ; simple chancre ; phagedenic 
chancre or bubo; bubo of soft chancre; venereal, virulent, or absorption 
buboes. — Do not include: Infecting or syphilitic chancre or bubo (36, 1) ; 
chancre of the mouth (36, 1) ; scrofulous bubo (35) ; suppurating bubo 
(144); plague bubo (15); bubo (without qualification) (144). (Morbidity 
statistics onlyj 

GONORRHOEA (five years and over). Include: Blennorrhcea ; ardor urinae; 
urethritis; military drop; balanitis; balanorrhagia ; balanoposthitis, vagi- 
nitis; gonorrhoea! cystitis, orchitis, buboes, arthritis, rheumatism, or con- 
junctivitis of the adult; or gonorrhceal or blennorrhagic ophthalmia of the 
adult— Do not include: Vaginismus (132) ; vaginalitis (126). — Frequent 
complications: Bubo; adenitis; cystitis; orchitis. 

EtHCEAL Aifections of the Child. 1 Include: Blennorrhagic or gonor- 
rheal conjunctivitis of the child; gonorrhceal vulvitis, etc. 



I This title takes account only of children under five years of age. 



USUAL CAUSES OF DEATH 



451 



39. Cancer and other Malignant Tumors of the Buccal Cavity. Include: 

Cancer of the mouth, lips, tongue, roof of the mouth, velum of palate, maxilla, 
jaw. parotid gland, and tonsil: sarcoma of soft palate; epithelioma, or 
carcinoma, or cancroid of these organs; smoker's cancer. 

40. Cancer and other Malignant Tumors of the Stomach and Liver. 1 In- 

clude: Cancer of the oesophagus; cancer of the cardia ■ cancer of the py- 
lorus: carcinoma or scirrhus, or colloid or encephaloid tumor of these 
organs: gastrocarcinoma ; tumor of the stomach; scirrhus of liver or 
stomach: hepatic cancer. — Do not include: lhematemesis (104). 

41. Cancer and other Malignant Tumors of the Peritoneum, Intestines, and 

RECTUM. Include: Cancer, carcinoma, scirrhus, encephaloid, -cancroid, or 
epithelioma of the colon and anus : retroperitoneal sarcoma. 

42. Cancer and other Malignant Tumors of the Female Genital Organs. 

Include: Cancer of the uterus (womb), ovary, vagina, vulva; carcinoma, or 
encephaloid. or colloid tumor, or heteromorphous or neoplastic growth, or 
cancroid, or sarcoma, or epithelioma of these organs. 

43. Cancer and other Malignant Tumors of the Breast. Include: Carcinoma, 

or scirrhus, or encephaloid. or heteromorphous or neoplastic growth, or can- 
croid, or epithelioma of the breast or nipple. 

44. Cancer and other Malignant Tumors of the Skin. Include: Cancroid 

(without qualification) ; epithelioma or epitheliomatous tumor (without 
qualification) ; cancer of the ear, face, nose, or cervicofacial region; " noli- 
me-tangere;" rodent ulcer. — Do not include : Esthiomene (33): lupus (33). 

45. Cancer and other Malignant Tumors of other Organs, or of Organs not 

specified. Include: Abdominal cancer; pelvic cancer; cancer of the lung, 
of the kidney, of the bladder, and of the prostate ; cancerous goitre ; thyro- 
sarcoma ; sarcohydrocele ; cancer of the bone ; osteosarcoma ; cancerous or 
sarcomatous tumor of the neck; carcinoma, or scirrhus, or encephaloid. or 
cancerous ulcer, or malignant tumor, or sarcoma, or malignant fungus of 
these organs, or of other organs not specified ; chimney sweeps' cancer : 
Lobstein's cancer ; fungus hsematodes ; sarcoma of leg; lymphosarcoma, etc. 
— Do not include: Cancer of the oesophagus (40) ; cancer of the anus (41) ; 
cancer of the ovary, vagina, or vulva (42). 

46. Other Tumors (Tumors of the Female Genital Organs excepted). Include: 

Tumor (without qualification); abdominal tumor; intestinal tumor; vas- 
cular or erectile tumor ; angioma; lymphoma; lymphadenoma ; lymphato- 
cele ; adenoma; chondroma; osteoma; myoma; lipoma; wen; grub; 
sebaceous tumor; cystoma. — Do not include: Cancer and its synonyms < 39 
45; ; tumor of the stomach (40) ; stercoraceous tumor (108) ; tumor of the 
uterus (129); hydatid tumor (ill) ; cyst of the ovary (131) ; aneurismal 
tumor (81;; varicose tumor (83); polyp of the ear (76): polyp of the 
nasal or nasopharyngeal fossae (87): uterine polyp (129); osteoma (140). 

47. Acute Articular Rheumatism. Include: Rheumatic arthritis; rheumatic 

meningitis; abdominal or cerebral rheumatism; rheumatic vertigo: rheu- 
matic endocarditis, pericarditis, pleurisy, peritonitis, etc- -Do not include: 

ganic heart disease of rheumatic origin (79); rheumatic iritis (75) 
arthritis deformans 148): gonorrhoea! rheumatism (37 and 38). 



' in countries where the words "organic lesion ot the stomach" always signify "cancel <-i the 
stomach" classify thi In countries where, on the contrary, this is not always 

so, classify them under No. 



|;j POST MORTEM EXAMINATIONS 

CHRONK RHEUMATISM \\n Gout. Include: Arthritis deformans; articular 
rheumatism; Heberden's disease, podagra; rheumatic gout; rheumatism 
( unqualified >. 

Scurvy. Include: Scorbutus; Werlhoff's disease; Barlow's disease. 

Diabetes. Include'. Diabetes insipidus and mellitus; Hirshfield's disease; 
diabetic gangrene and coma; glycosuria. — Frequent complications: Pneu- 
monia: furunculosis ; gangrene; cerebral hemorrhage and cerebral soften- 
ing : tuberculosis. 

51. Exophthalmic Goitre. Include: Exophthalmia ; Basedow's, Graves's, Parry's, 

Stokes's disease; exophthalmic cachexia. — Frequent complications: Hyper- 
trophy of the heart; cachexia. 

52. Addison's Disease. Include: Adrenal disease. Freq. complic: Cachexia; ascites. 
Leukjemia. Include: Adenoleuksemia ; leucocythsemia ; Hodgkin's disease; 

pseudoleukemia. — Freq. complic: Hemorrhage; ascites; apoplexy; cachexia. 

54. Ax.i.mia; Chlorosis. The cause of the anaemia should always be given. 

Include: Pernicious anaemia. — Do not include: Cerebral anaemia (74b). 

55. Other General Diseases. Include: Autointoxication; infectious fever ; viru- 

lent disease (without explanation) ; visceral steatosis; acromegalia; amy- 
loid or generalized fatty degeneration; adiposis; obesity; polysarcia. 

Alcoholism, Acute or Chronic. Include: Drunkenness; ethylism; alcoholic 
intoxication; alcoholic delirium; alcoholic dementia; delirium tremens; 
absinthism; absinthsemia ; dipsomania; " mania-a-potu." — Do not include: 
Alcoholic cirrhosis (112) ; general alcoholic paralysis (67) ; atheroma (81) ; 
or any other disease attributable to alcohol; intoxication amblyopia (75). 

Saturnism. Include: Saturnine colic; lead colic; painter's colic; lead en- 
cephalopathy ; lead paralysis ; chronic lead poisoning ; all conditions char- 
acterized as " saturnine." 

Other Trade or Occupation Intoxications. Include: Mercurial (hydrar- 
gyrism) ; phosphorus, arsenical, or other intoxication, when special mention 
by the physician makes it clear that the intoxication is the result of a trade. 
Failing in this specific declaration, it should be classed in one of the condi- 
tion- under No. 59. — Do not include: alcoholism (56). 

Chronic Poisonings. Include: Morphinism; cocainism; chronic er- 
tism. — Do not include: Amblyopia from intoxication (75). Note the 
remark under No. 58. 

II. DISEASES OF THE NERVOUS SYSTEM AND OF THE ORGANS 
OF SPECIAL SENSE. 

60. ENCEPHALITIS. Include: Cerebral fever; phrenitis ; poliencephalitis. 

SlM PL] MENINGITIS. Include: Meningitis (without qualification) ; meningo- 
encephalitis ; pachymeningitis. 
Epidemic Cerebrospinal Meningitis. Do not include: Tuberculous menin- 
gitis (or other synonym) (28) ; rheumatic meningitis (47). 

.1 Locomotor Ataxia. Include: Duchenne's disease; posterior 
rosis; tabes dorsalis; cerebral ataxia; posterior spinal sclerosis; pro- 
taxia; progressive spastic ataxia. 

- \ l Cord. Include: Disease of the cord; sclerosis 
in plaques; symmetrical sclerosis; lateral sclerosis; sclerosis (without 
qualification); Charcot's disease; Morvan's disease; syringomyelias ; hem- 
orrhage into the spinal cord; haematomyelitis ; haematorrhachia ; myelitis; 



USUAL CAUSES OF DEATH 453 

medullary congestion; affections of the bulb; bulbar paralysis; spinal 
paralysis : paralysis agitans ; trembling paralysis ; ascending paralysis ; 
essential paralysis of infancy : tatty or amyloid degeneration of the cord ; 
Parkinson's disease : Friedreich's disease ; medullary compression or com- 
pression of the cord: progressive muscular atrophy: fatty degeneration of 
muscle; atrophic muscular paralysis : amyotrophia; amyotrophic paralysis: 
atrophic paralysis : pseudohypertrophic paralysis ; etc. 

64. Cerebral Coxgestiox and Hemorrhage. Include: Apoplexy; cerebral apo- 

plexy; meningeal apoplexy; serous apoplexy; cerebral atheroma: oedema 
of the brain ; cerebral effusion ; cerebellar hemorrhage ; meningeal hemor- 
rhage ; cataplexia : apoplectic dementia: stroke (unqualified): clot on 
brain. — Frequent complications: Hemiplegia; paralysis. 

65. Cerebral Softexixg. Do not include: Senile dementia (154). — Frequent 

complications: Hemiplegia; paralysis; pulmonary congestion. 

66. Paralysis without Specified Cause. Include: Paralysis (without qualifica- 

tion) ; hemiplegia: facial paralysis; generalized paralysis (not insane or 
unqualified) ; palsy. — Do not include: Diphtheritic paralysis (9) ; atrophic 
muscular paralysis (63) ; general paralysis (67) ; paralytic cachexia (maras- 
mus) (67) ; paralytic dementia (idiocy) (67) ; shaking (67) or trembling 
paralysis (63) ; bulbar paralysis (63) ; ascending paralysis (63) ; essential 
paralysis of infancy (63) ; labioglossolaryngeal paralysis (74b) ; paralysis 
of the velum palati (101) ; paralysis of the muscles of the eye (75). 

67. General Paralysis. Include: Paralytic lunacy; paralytic dementia; para- 

lytic cachexia; paralytic marasmus; diffuse meningo-encephalitis ; diffuse 
peri-encephalitis. — Do not include: Generalized paralysis (not insane) (66). 

68. Other Forms of Mental Aliexatiox. Include: Dementia; lunacy; un- 

soundness of mind ; hallucinations ; mania ; megalomania ; monomania ; 
delusions of persecution ; melancholia ; lypemania ; nostalgia ; insanity ; 
nosophobia ; necrophobia ; sitiophobia ; lycanthropy ; homesickness ; andro- 
mania ; nymphomania; priapism; satyriasis; mental disease. — Do not in- 
clude: Alcoholic dementia or delirium (56) ; delirium tremens (56) ; de- 
lirium (179) ; ursemic delirium (120) ; apoplectic dementia (64) ; paralytic 
dementia (67) ; choreic dementia (73) ; senile dementia (154) ; hysteria 
(74a). 

69. Epilepsy. Include: " Haut and petit mal ;'' disease of Herculo ; fit-: falling 

sickne-s. — Do not include: Epileptiform convulsions (70-71). 

70. Eclampsia (Xon-puerperal). 1 Include: Epileptiform convulsions (of adults). 

— Do not include: Scarlatinous eclampsia (7); uraemic eclampsia (120): 
eclampsia of children under five years of age (71 ). 

71. Coxvulsioxs of Childrex." Include: Eclampsia of young children; con- 

tractures of children; spasms. — Do not include: Trismus nascentium (72). 

72. Tetaxus. Include: Opisthotonos; emprosthotonos ; pleurosthotonos ; tri>- 

mus nascentium or neonatorum; lockjaw: idiopathic tetanus. 
CHOREA. Include: Choreic dementia; Bergeron'- disease; Si. Vitus's dance. 

74. Hysteria. Include: Hysterical anorexia; hysterical colic; all diseases clari- 
fied as "hysterical." (Morbidity statistics alone.) 

74a. Neuralgia. Include: Tic douloureux ; sciatica. (Morbidity statistics alone ) 



1 When a female of ctaildbearing age is designated as having been Btrit ken with " <■< lampsia," return 
the report to have the physician state whether or not the disease W8J puerperal. 
•- This title applies only to children under five years ol 



POST MORTEM KXAMINATIONS 

OTHER DlSl tSES OF rin: NERVOUS System. Include: Cerebral compression, 
cerebral tumor; acquired hydrocephalus ; neuroma; encephalopathia (with- 
out qualification); idiocy; imbecility; cretinism; gatism; amnesia; param- 
nesia: l«>ss of speech; aphasia; nervous or cerebral accidents; cerebral 
anaemia; neurosis; tic; convulsive tic; contracture; anaesthesia (not due 
external anaesthetic) ; neurasthenia; migraine; vertigo; somnambulism; 
catalepsy; boulimia; Landry's disease: symptomatic or Jacksonian epilepsy; 
athetosis; labioglossolaryngeal paralysis; amyloid or fatty degeneration of 
tlie nervous system, etc. — Do not include: Senile dementia, imbecility or 
senile gatism (154); syringomyelias (63); myxcedema (89); congenital or 
undescribed hydrocephalus (150). 

75. ] )iskases of the Eye and its Adnexa. Include: Ophthalmia; foreign bodies ; 
conjunctivitis (not including diphtheritic or gonorrheal conjunctivitis) ; 
pterygion; Pinguecula; keratitis of every description; staphy- 
loma: diseases of the cornea; arcus senilis; diseases of the sclerotic; dis- 
eases of the iris; iritis; diseases of the choroid; choroiditis; iridocho- 
roiditis; sclerochoroiditis ; glaucoma; diseases of the retina; retinitis; 
optic neuritis; amaurosis; amblyopia; amblyopia from intoxication; hemio- 
pia; hemeralopia ; nyctalopia; diseases of the lens; cataract; aphacia; 
parasites of the eye; ophthalmozoa ; coloboma; strabismus; strabotomy; 
paralysis of the muscles of the eye; nystagmus; styes; chalazion; blephar- 
itis; blepharoconjunctivitis; scrofulous blepharitis ; blepharophimosis ; ble- 
pharoplastia ; ectropion ; entropion ; trichiasis ; dacryoadenitis ; diseases of 
the lachrymal gland and lachrymal sac ; dacryocystitis ; dacryolithiasis ; 
dacryoma; lachrymal fistula; diseases and tumors of the orbit (undefined). 
— Do not include: Diphtheritic (9) or gonorrhceal (37-38) conjunctivitis; 
ocular cancer (45) or tuberculosis (s^) ; exophthalmic goitre (51) ; ex- 
ophthalmia (51). Many titles in 75 are never employed as causes of death. 
iLLICULAR Conjunctivitis. (Morbidity statistics alone.) 

75I). Trachoma. (Morbidity statistics alone.) 

I Diseases of the Ear. Include: Otitis; otorrhcea ; catarrh of the ear; hydro- 
titis ; foreign body in the auditory canal ; obstruction of the auditory canal ; 
poly]) of the ear; inflammation of the tympanum; "vertigo ab aure laeso;" 
Meniere's disease, or vertigo; caries of the labyrinth (?) ; deafness; deaf- 
mutism. — Do not include: Mumps (19). 

III. DISEASES OF THE CIRCULATORY APPARATUS. 

77. Pericarditis. Include: Cardiopericarditis ; hydropericarditis ; hydropneumo- 
pericarditis ; pericardial adhesions. — Do not include: Rheumatic pericarditis 
(47) ; endopericarditis (78) ; pleuropericarditis (94) ; pneumopericarditis 
(93). 

7s A.CUTE ENDOCARDITIS. Include: Endocarditis (without qualification); myo- 
carditis, acute or without qualification; endopericarditis. — Do not include: 
Rheumatic endocarditis (47), or the other cardiac accidents which may 
supervene in the course of an attack of rheumatism. 

vie Diseases of the Heart. Include: Aortic, mitral, tricuspid, or car- 
diac affection or lesion ; cardiac or valvular insufficiency or stenosis of the 
valves of the heart ; cardiac cachexia ; hypertrophy of the heart ; dilatation 
of the heart ; cardiectasis ; steatosis of the heart ; degeneration of the heart ; 
cardiopathy; cardiosclerosis; cardiovascular sclerosis; cardiomalacia ; car- 
diostenosis; labored heart; tachycardia; rupture of the heart; cardior- 



USUAL CAUSES OF DEATH 



455 



rhexia; cardiac palpitation: asystole: cardiac asthma. — Do not include: 
Cardiac accidents (undetermined) (86) ; persistence or patency of the fora- 
men of Botallo (150). — Frequent complications: Dropsy; bronchitis and 
pneumonia: albuminuria; embolism; thrombosis. 

So. Angina Pectoris. Include: Cardialgia; sternaigia; neuralgia of the heart. 

81. Affections of the Arteries, Atheroma, Aneurism, etc. Include: Arteritis: 
fatty degeneration of arteries ; arteriosclerosis ; atheroma of arteries : arte- 
riectasis; aortic ectasis ; Hodgson's disease; atresia of Lhe pulmonary ar- 
tery: aortitis; aneurismal tumor. — Do not include: Aortic affection (79). 
Embolism and Thrombosis. Include: Thrombosis (without qualification) ; 
phlegmasia alba dolens (non-puerperal) ; embolic pneumonia. — Do not in- 
clude: Embolism (puerperal) (140). 

83 Affections of the Veins (Varices, Hemorrhoids, Phlebitis, etc.). Include: 
Pneumophlebitis : varicose ulcer; varicocele. — Do not include: Puerperal 
phlebitis (137) : vascular or erectile tumor (46) ; angioma (46). 

84. Affections of the Lymphatic System. Include: Angioleucitis ; adenopa- 

thia : lymphangeitis ; adenitis. — Do not include: Suppurative adenitis (144) ; 
adenophlegmon (144) : leucaemic adenitis (53) ; lymphatism (35) ; bubo 
(36a and 144) : adenoma (46) : lymphoma (46) ; lymphadenoma (46). 

85. Hemorrhages. Include: Hemorrhage (without qualification) ; internal hem- 

orrhage ; haemophilia ; epistaxis ; stomatorrhagia ; cutaneous hemorrhage ; 
purpura hemorrhagica. — Do not include: Cerebral hemorrhage (64) ; cere- 
bellar hemorrhage (64) ; meningeal hemorrhage (64) ; pulmonary hemor- 
rhage (99) ; haemoptysis (99) ; haematemesis (104) ; intestinal hemorrhage 
(109); hematuria (121); uterine hemorrhage (135 or 128, depending on 
whether it is or is not puerperal) ; metrorrhagia (128 or 135) ; umbilical 
hemorrhage (under three months) (152); traumatic hemorrhage (166). 

86. Other Affections of the Circulatory Apparatus. Include: Cardiac acci- 

dents (undetermined); angiectasis ; angiectopia ; affections of the great 
vessels; permanently slow pulse. — Do not include: Vascular naevus (150). 

IV. DISEASES OF THE RESPIRATORY APPARATUS. 

Sj. Diseases of the Nasal Foss.e. Include: Coryza; cold; polypus of the nasal 
or nasopharyngeal fossa; ozsena ; abscess of the nasal fossa; adenoid vege- 
tations. — Do not include: Epistaxis (85) ; syphilitic coryza (36). 

88. Affections of the Larynx. Include: Acute, chronic, erysipelatous, oedema- 
tous, phlegmonous, or stridulous laryngitis; aphonia; loss of voice; false 
croup: -pa-modic croup; stridulous croup ; oedema of the glottis ; spasm of 
the glottis: polypus of the larynx ; stricture of the larynx ; laryngotomy.— 
Do not include: Tuberculous laryngitis (26) ; laryngeal tuberculosis (26) ; 
croup (9); diphtheritic laryngitis and its synonyms (9); foreign bodies in 
the larynx (176). 
Affections of the Thyroid Body. Include: Goitre; thyrocele; myxce- 
dema: pachydermic cachexia.— Do not include: Exophthalmic goitre (51). 

90. Bronchitis, Acute. 1 Include: Capillary bronchitis; tracheitis; tracheobron- 
chitis; broncho-alveolitis.— Do not include: Bronchopneumonia (92) ; spe- 
cific bronchitis or other synonym of pulmonary tuberculosis (see No. 27) ; 
fetid bronchitis (96) : summer bronchitis (09). 

1 See 1 ■ 



POST MOP IT.M EXAMINATIONS 

91. Bronchitis, Chronic 1 Include: Mucous bronchitis (pituitous) ; catarrh 
(without qualification); bronchial, pituitous, pulmonary, or suffocating 
catarrh; bronchorrhoea ; dilatation of the bronchi; bronchiectasis. — Do not 
include: Fetid bronchitis (96) : tuberculous bronchitis (27). 

92 Bronchopneumonia. Include: Catarrhal, deglutition, and aspiration pneu- 
monia.— Do not include: Capillary bronchitis (90). 

93, Pneumonia. 1 Include: Croupous pneumonia; fluxion of the lung; pleuro- 
pneumonia: pneumopleurisy ; splenopneumonia ; apical pneumonia; peri- 
pneumonia; pneumopericarditis ; typhoid and alcoholic pneumonia. — Do not 
include: Caseous pneumonia (27) ; specific, bacillary, or any synonym of 
pulmonary tuberculosis (27) ; pulmonary congestion (95). 

04. PLEURISY. Include: Pleuropericarditis ; pleuritic or thoracic effusion ; pneu- 
mothorax: liydropneumothorax; pyothorax ; pleural vomica ; pneumopyo- 
thorax; hemothorax; thoracentesis; empyema; pleural adhesions. — Do 
not include: Pleurodynia (99). 
Pulmonary Congestion and Pulmonary Apoplexy. Include: (Edema of the 
lungs; hypostatic pneumonia. 
lNGRENE OF THE Lung. Include: Fetid bronchitis; mortification of lung. 

97. Asthma. Do not include: Cardiac asthma (79); suffocating catarrh (91); 

hay fever (99). 

98. Emphysema of the Lungs. Include: Emphysema (without qualification). — 

Do not include: Subcutaneous emphysema (145). 

99. Other Diseases of the Respiratory Apparatus (Phthisis excepted). In- 

clude: Tracheostenosis; pleurodynia; pneumopathy; hydatids of the lung ; 
pulmonary calculus; abscess of the lung; pulmonary anthracosis ; inter- 
stitial pneumonia; cirrhosis of the lung; secondary sclerosis; hay fever 
i summer bronchitis or catarrh). To be also included when their nature is 
not indicated : Organic lesion of the lung ; pulmonary accidents ; haemop- 
tysis; spitting of blood; pulmonary hemorrhage; pneumorrhagia ; bron- 
chorrhagia; tracheotomy. — Do not include: Cancer of the lung (45). 

V. DISEASES OF THE DIGESTIVE APPARATUS. 

100. Affections of the Mouth and its Adnexa. Include: Diseases of the gums; 

epulis; gingivitis; ulorrhagia; glossitis; diseases of the tongue (except 
cancer); parotid tumor; parotiditis; salivary fistula; ranula ; thrush; 
the teeth; odontalgia; dental caries; staphylitis ; staphylo- 
plasty; staphylorrhaphy. — Do not include: Cancer of the lips or tongue 
(39); chancre of the mouth (36a); noma (142); mumps (19); gangrene 
of the mouth (142) ; diseases of the palate (146 or 36) ; fracture of the 
maxilla (164); necrosis of the maxilla (146); paralysis of the velum 
palati (101). 

101. Affections OF the Pharynx. Include: Angina or Ludwig's disease; anginas 

of all descriptions (except diphtheritic angina and its symptoms; see Diph- 
theria, No. 9); amygdalitis; quinsy; abscess of the fauces, throat, or 



1 Return to the physi< ian the reports given in as "bronchitis," in order that he may specify acute or 
chronic. When the physician fails thus to answer, classify under No. 90 all reports relating to children 
under five years of ae;e, and under No, 91 all reports as to those of greater age. 

- In < onntries where " apii al pneumonia" is always synonymous with " phthisis," class this diagnosis 
Under No 27. In countries, on the I ontrary, where this is not constant, class under No. 93. 



USUAL CAUSES OF DEATH 4 ~- 

retropharynx ; paralysis of the velum palati ; elongation of the uvula ; 
pharyngitis: tonsillitis. — Do not include: Angina pectoris (80) ; cardiac 
angina (So) ; scarlatinal angina (7). 

102. Affections of the (Esophagus. Include: Foreign bodies in the oesophagus; 

wound of the oesophagus; stricture of the oesophagus (except from can- 
cer); spasm of the oesophagus; oesophagotomy. — Do not include: Cancer 
of the oesophagus (40) ; syphilitic stricture of the oesophagus (36). 

103. Ulcer of the Stomach. Include: Round ulcer. — Frequent complications: 

Hamiateinesis ; perforations of the stomach ; peritonitis. 

104. Other Affections of the Stomach (Cancer excepted). 1 Include: Dilata- 

tion of the stomach ; paresis of the stomach ; dyspepsia ; apepsia ; gas- 
tritis ; gastrohepatitis ; foreign body in the stomach ; gastrotomy ; perfora- 
tion of the stomach (non-traumatic); gastralgia ; "vertigo a stomacho 
laeso;" catarrh of the stomach; indigestion. To be also included when 
their nature is not indicated : Gastrorrhagia ; haematemesis ; gastric hemor- 
rhage. — Do not include: Gastro-enteritis (105 or 106, according to age). 

105. Diarrhoea and Enteritis (under two years). Include: Gastro-enteritis or 

gastrocolitis of children ; infantile enteritis ; cholera infantum ; athrepsia. 
This title only considers these ailments in children under two years. 
105a. Diarrhoea and Enteritis, Chronic (under two years). Include: Athrepsia. 

106. Diarrhoea and Enteritis (two years and over). Include: Gastro-enteritis 

or gastrocolitis of adults; enteritis of adults; diarrhoea of adults; lien- 
enteritis; intestinal ulcerations; colitis; intestinal colic; flatulent colic; 
inflammatory colic. Do not include: Tuberculous enteritis (29). 

107. Intestinal Parasites. Include: Helminthae; oxyuri; taenia, of all kinds 

and descriptions : solitary worm ; ascaris lumbricoides ; trematodes ; tricho- 
cephalus ; ankylostomes ; colic from worms. 

108. Hernias and Intestinal Obstructions. Include: Internal strangulation; 

intestinal invagination ; stercoral tumors ; ileus ; intestinal occlusion ; volvu- 
lus ; hernial colic; hernial gangrene. The following to be included when 
their nature is not specified : Merocele ; sarco-epiplocele ; sarco-cpiplom- 
phalitis; kelotomy ; herniotomy; artificial anus; stercoraceous vomiting. 
— Do not include: Laparotomy (without other qualification) (46 and 179)- 
— Frequent complication: Peritonitis. 

109. Other Affections of the Intestines. Include: Paralysis or paresis of the 

intestine; enteroptosis ; constipation; stercorsemia ; intestinal calculi ; in- 
testinal perforation; foreign bodies in the intestine or rectum; rectitis. 
Include also the following diseases when their nature is not indicated, and 
these operations when their cause is not specified: Enterotomy; artificial 
anus; cnterrhagia ; intestinal hemorrhage ; melaena ; prolapsus of the rec- 
tum ; stricture of the rectum. — Do not include: Stercoral tumor (108); 
intestinal invagination and its synonyms (108) ; typhlitis and appendicitis 
(118) ; perityphlitis C118). 
109a. Diseases of the Anus and Fecal Fistulas. Include: Proctitis; periproc- 
titis; proctocele; proctoptosis; fissure of the anus ; abscess of the margin 
of the anus; fistula of the anus, either fecal or rectovaginal Do not in 
elude: Urinary fistuke, even when these involve the rectum (124) ; artifi 
cial anus (108) (morbidity statistics alone); unnatural anus (108); im 
perforate anus (150). (For morbidity statistics alone.) 

lion under No. 40 as to " organi< lesion of tl><- stoma* h." 



{ -S POST MORTEM EXAMINATIONS 

[10. \> i m Yi-unw ATROPHY OF rHE LIVER. Include: Pernicious icterus; paren- 
chymatous hepatitis; Weil's disease. — Do not include: Icterus (without 
qualification) (114); chronic icterus (114) ; icterus of the new-born (under 
three months > (151). 

111. HYDATID Tl MORS OF iiik Livkk. Include: Hydatid cyst; hydatids (without 
qualification > ; echinococci. 

1 1 j. CIRRHOSIS Ol rHE LIVER. Include: Cirrhosis (without qualification); alco- 
holic cirrhosis; interstitial cirrhosis; biliary cirrhosis; amyloid or fatty 
degeneration of the liver; slow atrophy of the liver; steatosis of the liver; 
alcoholic, interstitial, or chronic hepatitis. — Do not include: Organic lesion 
of the liver (114); hypertrophy of the liver (114). — Frequent complica- 
tions: Dropsy; hemorrhage; pneumonia; tuberculosis. 

113. Biliary Calculi. Include: Hepatic calculi; biliary lithiasis; hepatic colic. 

1 1.4. Other Affections of the Liver. Include: Abscess of the liver; hepatitis; 
hepatitis, acute; angiocholitis ; cholecystitis; hepatocystitis ; choluria. To 
be also included when their precise nature is not indicated: Organic lesion 
oi the liver; tumor of the liver; hypertrophy of the liver; acholia ; cho- 
laemia; icterus (over three months); chronic icterus; jaundice; hepatic 
n. — Do not include: Acute yellow atrophy of the liver (no): 
icterus of the new-born (151). 

115. Affections of the Spleen. Include: Splenitis; splenopathia ; megalosple- 
nia; splenocele. — Do not include: The affections of the spleen due to 
leukaemia (53) or malaria (4). 

[10. Peritonitis, Simple (Puerperal excepted). 1 Include: Peritonitis (without 
qualification); peritonitis, chronic; peritoneal adhesions; epiploitis ; metro- 
peritonitis pelviperitonitis. — Do not include: Tuberculous peritonitis (29) ; 
cancer of the peritoneum (41) ; puerperal peritonitis (137) ; rheumatic 
peritonitis (47). 

1 17. ( )ther Affections of the Digestive Apparatus (Cancer and Tuberculosis ex- 
cepted). Include: Diseases of the pancreas (cancer excepted). 

ii8. Appendicitis and Abscess of the Iliac Fossa. Include: Iliac phlegmon 
or abscess; typhlitis; perityphlitis; typhlodicliditis ; appendicitis. — Do not 
include: Pelvic (130) or periuterine abscess; pelvic suppuration (130). 

VI. DISEASES OF THE GENITO-URINARY APPARATUS AND 
ITS ADNEXA (NOT INCLUDING VENEREAL DISEASES). 

119. Nephritis, Acute. Do not include: Scarlatinous nephritis (7); chronic 
nephritis (120) ; tuberculous nephritis (33) ; nephritis of pregnancy (138). 
Bright's Disease. Include: Chronic, albuminous, interstitial, or parenchy- 
matous nephritis; albuminuria; amyloid or fatty degeneration of the kid- 
ney: amyloid kidney; steatosis of the kidney ; renal sclerosis. To be in- 
cluded when their precise nature is not indicated: Uraemia; uraemic 
eclampsia: uremic delirium; uraemic coma. — Do not include: Organic 
lesion of the kidney (121) ; puerperal uraemia (138) ; cardiac albuminuria 
(79). — Frequent complications: Anasarca; dropsy; convulsions; hemor- 
rhages: cerebral apoplexy; pneumonia. 



; When a female <>i childbearing age is returned as having been stricken with "peritonitis," with- 
er explanation, the report should be returned in order that the physician may specify whether or 
tion was puerperal. 



USUAL CAUSES OF DEATH 4 ~ t) 

121. Other Diseases of the Kidneys and their Aj>nexa. Include: Pyelitis; 
anuria ; renal congestion ; renal ectopia ; nephroptosis ; floating, motile, or 
displaced kidney; movable kidney ; renal cysts ; polycystic kidney ; hydro- 
nephrosis: hematuria: perinephritis: perinephritic and nephritic abscess: 
pyelonephritis: nephropyosis. To be also included when their nature is 
not specified: Organic lesion of the kidney: nephrorrhagia. 

Calculi of the Urinary Tract. Include: Renal, ureteral, nephritic, vesical. 
or urinary calculus ; nephritic colic : nephrolithiasis; gravel: stone; cal- 
culous affections; urinary lithiasis; lithotrity; lithoclasty.— Do not in- 
clude: Prostatic calculus (125). 

Diseases of the Bladder. Include: Cystitis, acute or chronic; vesical or 
ureteral catarrh: cystorrhagia ; tumor of the bladder; cystocele ; cystop- 
tosis: foreign body in the bladder; cystotomy; retention of urine; 
dysuria; paralysis and section of bladder; vesical inertia: incontinence of 
urine: tenesmus of the bladder. — Do not include: Hematuria (121) ; uri- 
nary fistula?, even when they involve the bladder (124) ; cystosarcoma (45). 

Diseases of the Urethra. Include: Urinary abscess, etc.; ankylurethria ; 
foreign bodies; urethrotomy; urinary fistula (urethral, urethrorectal, vesi- 
corectal, or vesicometrorectal) ; urinary infiltration; urinary intoxication; 
urethralgia; urethrorrhagia; urinaemia; stricture of the urethra ; urethro- 
stenosis; urethroplasty: urethrorrhaphy ; stricture (male). — Do not in- 
clude: Ureteral catarrh (123) ; retention of urine (123). 
125. Diseases of the Prostate. Include: Hypertrophy of the prostate; prosta- 
titis: abscess of the prostate; prostatic calculus. — Do not include: Cancer 
of the prostate (45) ; tuberculosis of the prostate (33). 

XON-VENEREAT. DISEASES OF THE GENITAL ORGANS OF THE MALE. Include: 

Phimosis; paraphimosis; amputation of the penis; seminal losses; sper- 
matorrhoea: orchitis; epididymitis; funiculitis ; hydrocele; hematocele 
of the testicle, cord, or scrotum; castration (in man) ; Malassez's disease. 
— Do not include: Cancer of the testicle (45) ; tuberculosis of the testicle 
«33.»: sarcohydrocele (45); syphilitic sarcocele (36); varicocele (83). 
Metritis (non-puerperal or unqualified). Include: Ulcer of the uterus; 
ulceration of the neck (of the womb) ; endometritis. 

12S. Uterine Hemorrhage, Xon-puerperal. Include: Metrorrhagia; menorrha- 
gia ; tamponage of the vagina or uterus. 

I2<;. Uterine TUMOR (not cancerous). Include: Fibroid tumor, or fibroid of 
body of the uterus; hysteromyoma ; uterine polypus; fungous or fungoid 
tumors of the uterus: Huguier's disease. 

130. Other Diseases of the Uterus. Include: Procidentia of uterus; uterine 

or vaginal catarrh ; deviation, anteflexion, retroflexion, anteversion, falling 
or prolapse of the uterus ; prolapse of the vagina ; uterine prolongation ; 
amenorrhoea; hypertrophy of the neck of the uterus; dysmenorrhea ; 
organic lesion of the uterus; hysterectomy; hysterotomy; metrotomy; 
ablation of the uterus; abscess of the pelvis; periuterine or retro-Uterine 
abscess or phlegmon; pelvic suppuration; leucorrhoea; fluor albus 
(white-: vaginal flow; white flux).— Po not include: Puerperal diseases 
(134 and 141 ) : abscess of the iliac fossa (118). 

131. Cysts AND OTHER Tumors of the Ovary. Include: Ovariotomy; castration 

fin the female). Dermoid cyst often classified better lure than under [46 



POST MORTEM EXAMINATIONS 

[32. < h 111 k 1 Diseases of rnr. I rEN] 1 \i. Organs of the Female. Include: Vaginis- 
mus; tumors of the vagina; ovaritis; salpingitis; salpinx; metrosalpin- 
gitis ; hematosalpinx ; pyosalpinx ; abscess and tumors of the vulvovaginal 
inds; vulvitis; periuterine or retro-uterine hematocele. — Do not include: 
Urinary fistula (124); stercoral fistula? (109a); even when they involve 
the genital organs. King makes a subheading of "Diseases of tubes." 

133. \'o\ puerperal Diseases of the Breast (Cancer excepted). Include: Mam- 

mitis; abscess of the breast (non-puerperal); cyst of the breast; cystic 
disease ^i Reclus; tumor of the breast (without qualification, or non- 
cancerous) ; amputation of the breast. — Do not include: Fistula of the 
breast (puerperal, or without qualification) (43); mammary cancer (43). 

VII. THE PUERPERAL STATE. 

Rem VRKS. — It often happens that physicians neglect to note the puerperal char- 
acter of the disease; hence the following rule for the guidance of those whose duty 
it is to collect statistics. " Whenever a female of childbearing age is noted as 
dead from a disease which may be puerperal, the report should be returned to the 
reporter, in order that he may state explicitly whether or not the disease was puer- 
peral." The following are these diseases : Peritonitis; pelviperitonitis; metroperi- 
tonitis: septicaemia; hemorrhage; metrorrhagia; eclampsia; phlegmasia alba dolens ; 
phlebitis; lymphangeitis ; embolism; sudden death; abscess of the breast. 

134. Accidents of Pregnancy. Include: Miscarriage (death of mother) ; abor- 

tion (death of mother) ; hemorrhage of pregnancy; incoercible vomiting; 
rupture of tubal pregnancy ; ablation of the pregnant tube ; difficulties and 
fatigues supervening in the course of pregnancy. 
134a. Labor, Normal. (Morbidity statistics only.) 

135. Puerperal Hkmorrhage. Include: Puerperal metrorrhagia; post-partum 

hemorrhage. 

136. Other Accidents of Labor. Include: Dystocia; Cesarean section; rupture 

of the uterus ; metrorrhexia ; laceration or rupture of the perineum ; peri- 
neorrhaphy; placenta previa; malposition, retention, detachment, or apo- 
plexy of the placenta; cephalotripsy ; embryotomy (adult); symphyseot- 
omy ; version ; application of forceps ; uterine inversion. 

137. Puerperal Septicaemia. Include: Puerperal fever; puerperal infection; puer- 

peral endometritis ; puerperal salpingitis ; perimetrosalpingitis, or phlegmon 
of the broad ligament, or diffuse pelvic puerperal cellulitis ; puerperal peri- 
tonitis, metroperitonitis, phlebitis, lymphangeitis, or pyohsemia. — Do not in- 
clude: Septicaemia (without qualification) (20). 
[38. Puerperal Albuminura and Eclampsia. Include: Puerperal uraemia; ne- 
phritis of pregnancy; eclampsia of women in labor; epileptiform convul- 
sions of women in labor; puerperal tetanus. 

139. Phlegmasia Alba Dolens, Puerperal. Do not include: Phlegmasia alba 

. non-puerperal (82). — Frequent complications: Gangrene; embolism. 

140. OTHER PUERPERAL Accidents; Sudden Death. Include: Puerperal embo- 

lism; puerperal thrombus; sudden death in the puerperium; consequence 
of labor (without other explanation) ; subinvolution of uterus. — Do not 
include: Sudden death, non-puerperal (178) ; puerperal scarlatina (7). 

141. Puerperal Diseases of the Breast. Include: Fissure of the nipple (puer- 

peral) ; circumscribed abscess; abscess of the breast (puerperal); fistula 
of the breast (puerperal or without further indication). 



USUAL CAUSES OF DEATH , m 



VIII. DISEASES OF THE SKIN AND CELLULAR TISSUE. 

142. Gangrene. Include: Eschar: sphacelus; gangrene, dry ; gangrene, senile; 

gangrene of the extremities ; gangrene of the mouth ; gangrene of the 
vulva, etc.; noma; Raynaud's disease. — Do not include: Gangrene of the 
lung (96); hernial gangrene (108); gangrenous erysipelas (18 or 144). 

143. Furuncle (Carbuncle"). 1 Not included: Biskra. Aleppo, or Medina button (145). 

144. Phlegmon: Warm Abscess. Include: Abscess (.without qualification); 

phlegmonous tumor : adenophlegmon; suppurative adenitis ; bubo (with- 
out qualification) ; suppurating bubo ; diffuse phlegmon ; phlegmonous or 
gangrenous erysipelas ; panaris ; whitlow ; abscess of the mediastinum ; 
vomica (without any other indication). — Do not include: Bacillary abscess 
(33); abscess of the fauces, throat, or retropharynx (101"); of the liver 
(114) ; of the iliac fossa (118) ; of the female pelvis (130) ; of the pros- 
tate (125); urinary (124): periuterine (130); of breast, non-puerperal 
(130) ; cold (31) ; by congestion (31) ; ossifluent (31) ; angioleucitis (84). 

145. Tinea Favus. (Morbidity statistics alone.) 

145a. Tinea Tonsurans, Trichophyton. Include: Tinea (without qualification). 
(Morbidity statistics alone.) 

145b. Pelades. (Morbidity statistics alone.) 

145c. Itch. (Morbidity statistics alone.) 

I45d. Other Diseases of the Skin and its Adnexa. Include: Erythema; urti- 
caria ; prurigo, pityriasis ; lichen ; psoriasis ; dermatitis ; eczema ; im- 
petigo ; aphtha ; herpes ; ecthyma ; elephantiasis Arabum ; pachyderma- 
titis ; polysarcia ; scleroderma ; cheloids ; fungoid mycosis ; seborrhcea ; 
trophoneuroses ; zona ; Wardrop's disease ; Biskra, Aleppo, or Medina 
button; Penjdeh ulcer; Cochin-China ulcer; pemphigus; myiasis. — Do 
not include: Pachydermatous cachexia (89) ; elephantiasis Graecorum (17). 

IX. DISEASES OF THE ORGANS OF LOCOMOTION. 

146. Affections of the Bones (Non-tuberculous). Include: Periostitis; perios- 

tosis ; osteitis ; osteoperiostitis ; osteomyelitis ; caries ; necrosis ; seques- 
trum ; perforation of the palatine vault; necrosis of the maxilla (non- 
phosphoric or without qualification) ; exostosis (without qualification) ; 
osteoma; osseous tumor; cranial tumor; foreign bodies in the frontal or 
other sinuses; mastoiditis; abscess of the frontal or maxillary sinus; 
osteomalacia; softening of bone ; rhachitis; scoliosis; lordosis; kyphosis. — 
Do not include: Caries of the petrous bone (76) ; dental caries (100) ; 
osteocopic pains (?f>)\ osteosarcoma i^)'- phosphorus necrosis (58). 

147. Arthritis and other Diseases of the Joints (Tuberculosis and Rheumatism 

excepted). Include: Arthritis; polyarthritis (non-vertebral); hydrarthro- 
foreign bodies in joints; arthrodynia ; arthropyosis ; arthrophytis ; 
ankylosis; arthralgia; arthrocele ; genu valgum. — Do no! include: Rheu- 
matic arthritic (47;. 
Vmputation.* Include: Only those cases in which the lesion, the cause for 
amputation, is not specified. — Do not include: Amputation of the breast 



ah. 



)((J POST MORTEM EXAMINATIONS 

: amputation of the penis ( 126) . — Frequent complications: Septi- 
caemia; erysipelas; tetanus; hemorrhage. 
140 Other Affections of mi s Org \ns of Locomotion. Include: Hygroma; peri- 
chondritis; disarticulation; tarsalgia; painful talipes valgus; retraction 
of the fingers or of the palmar aponeurosis; Dupuytren's disease; non- 
traumatic muscular rupture; muscular diastasis ; myodiastasis ; non-trau- 
matic rupture of a tendon; diseases of tendons; tenophytes ; tenosynovitis; 
tenotomy; tenorrhaphy; torticollis; lumbago; curvature. 

X. MALFORMATIONS. 

[50. Malformations (Stillbirths not included). Include: Malformation; mon- 
strosity; anomaly; arrest of development; congenital hydrocephalus; hydro- 
cephalus (without qualification) ; megalocephalus ; hydrorachia ; spina 
bifida: cncephalocele; podencephalia ; congenital eventration ; omphalo- 
cele: exomphalos; ectopia; imperforate anus, etc. ; hare-lip; cleft palate : 
anaspadias; hypospadias; cryptorchid; vascular nsevus ; polydactylia; syn- 
dactylia ; congenital club-foot ; talipes valgus, varus, or equinus, congenital ; 
congenital deafness or blindness ; persistence of the foramen of Botalio 
(foramen ovale). — Do not include: Coloboma (75); painful flat-foot 
(149); acquired hydrocephalus (74b); tuberculous hydrocephalus (28). 
King makes a separate subheading for hydrocephalus and cyanosis. 

XL EARLY INFANCY. 

150a. The New-born and Nurslings departing from Hospitals without having 
l \ Sick. (Morbidity statistics alone.) 

151. Congenital Debility, Icterus, and Sclerema. 1 Include: Premature birth 

1 not stillborn) ; atrophy (infantile) ; icterus or hepatitis of the new-born.: 
atelectasis of the lungs in the new-born; oedema of the new-born. 

152. Other Diseases of Early Infancy. Include: Umbilical hemorrhage; in- 

flammation of the umbilicus; cyanosis of the new-born. (This title has 
reference to children not more than three months old.) 
[53. Lack of Care. 

XII. OLD AGE. 

Senile Debility. Include: Senility; old age; cachexia (of the old) ; senile 
exhaustion; senile dementia. — Do not include: Senile gangrene (142). 

XIII. AFFECTIONS PRODUCED BY EXTERNAL CAUSES. 

Among suicides there should only be classed those in whom suicide or attempted 
suicide is clearly demonstrated. In collective suicides there should only be counted 
who have attained their majority. Minors ought to be regarded as the victims 
assination and placed under 176. 

i»k BY Poison. Include: Voluntary poisoning; voluntary absorption of 
sulphuric acid (or any other corrosive substance). — Do not include: Co- 
cainism (59); morphinism (59). 

■:. BY ASPHYXIA. Include: Suicide by the vapor of charcoal. 
I [anging ok Strangulation. Include: Hanging. 
Suicide by Drowning. 



USUAL CAUSES OF DEATH 



463 



159. Suicide by Firearms. 

160. Suicide by Cutting Instruments. 

161. Suicide by Jumping from High Places. 

162. Suicide by Crushing. 
103. Other Suicides. 

164. Fractures. Include: Separation of the epiphyses; fracture o\ the cranium. 

165. Strains. Include: Strains: ligament-stretching. (Morbidity statistics only.) 
105a. Luxations. Include: Subluxations; dislocations. 

166. Other Accidental Traumatisms. Include: Stabs; contusion; bites (non- 

venomous, non-virulent) ; crushing; railroad accidents (suicide excepted) ; 
wounds by cutting instruments (suicide not demonstrated) ; accidental 
falls: concussion of the brain; perforation of the cranium; traumatic 
hemorrhage ; traumatic fever ; traumatic eventration ; perforation of the 
abdomen or chest; all acute affections designated as ''traumatic;" wounds 
by firearms. King subdivides into: accidental gunshot wounds; injuries 
by machinery; injuries in mines and quarries; railroad accidents and in- 
juries: injuries by horses and vehicles; and other accidental traumatisms. 

167. Burns and Scalds. Include: Burns and scalds from steam, petroleum gaso- 

line, boiling liquid, etc. — Do not include: Conflagration (174). 

168. Burns from Corrosive Substances. Include: Burns by vitriol. 

169. Insolation. Include: Sunstroke. 

170. Freezing. Do not include: Effects of cold (new-born) (153). 
17 j. Electrical Shock. Include: Death from lightning. 

172. Accidental Submersion. Include: Drowning (non-suicidal). 

173. Prostration. Include: Fatigue. (Morbidity statistics alone.) 

173a. Inanition. Include: Hunger; insufficient food (new-born excepted); mis- 
ery. — Do not include: Lack of care (new-born) (153) ; lack of nutrition 
(new-born) (153) ; sitiophobia (68) ; hysterical anorexia (74a). 

174. Absorption of Deleterious Gases (Suicide excepted). Include: Asphyxia. 

accidental (pathological asphyxia and suicidal asphyxia excepted) ; as- 
phyxia by illuminating gas; asphyxia by stoves (fixed or portable); 
absorption of carbonic oxid ; conflagration; absorption of ammonium sul- 
phid; asphyxia by night-soil; absorption of chloroform; absorption of 
nitrous oxid. — Do not include: Asphyxia of the adult (without qualifica- 
tion) (179) ; asphyxia (under three months) (152). 

175. Other Acute Poisonings. Include: Every acute poisoning (suicide ex- 

cepted) ; antimony cholera; acute ergotism; absorption of venom; bite 
of serpent; accidental absorption of sulphuric acid or other corrosive sub- 
stances. — Do not include: Saturnism (57) ; hydrargyrism, etc. (58 or 
59) ; morphinism, chronic ergotism, etc. (59)- 

176. Other External VIOLENCE. Include: Accident (without oilier qualifica- 

tion) ; bad treatment (upon a child) ; capital punishment : foreign body in 
the larynx; foreign body in the trachea. King subdivides into: suffoca 
don; injuries at birth: homicide: and other externa] violence. 



XIV. ELL-DEFINED DISEASES 

The following titles will include only those conditions ill defined by the phy 
Hcian, whether from lack of sufficient data, or because the disease wag ill defined, or 
e the physician was negligent in making a complete diagn 



|fl| POST MORTEM EXAMINATIONS 

DROPSY. Include: Anasarca; ascites; oedema of the extremities or gener- 
alized oedema; organic lesion (not defined). — Do not include: (Edema of 
the new-born 1151): cedema of the glottis (88); oedema of the lungs 
; cedema of the brain (64). 

178. SUDDEN DEATH. Include: Syncope (followed by death). — Do not include: 
Puerperal sudden death (140), nor sudden death followed by an explana- 
tion, as "diabetic" (50) or "apoplectic" (64). 

170. Ill-defined or Unspecified Causes of Death. Include: Exhaustion or 
cachexia or debility (of adults); asthenia; adynamia; ataxo-adynamia ; 
ma; asthenic, hectic, colliquative, synochal, gastric, bilious, or pituital 
fever; gastric involvement; fever of dentition; paralysis of the heart (in 
German " herzlahmung" or " herzschlag," in English "heart failure"); 
cyanotic asphyxia (without indicated cause, the new-born excepted) ; or 
any other insufficient diagnosis. — Do not include: Exhaustion, cachexia or 
debility of the old (154) ; fever, ataxo-adynamic (1), continued (1), sum- 
mer, or hay (99) : asphyxia by external cause (156 or 174) ; cyanosis of 
the new-born ( [52 >. 
S Ni.i.r.ikTiis. Stillbirths are not included among deaths, as a stillborn child 
is one born dead. Still, it is wise to have a separate heading for them, 
including under congenital debility (151) and unknown (179) cases where 
the child lived after birth and a definite cause of death cannot be assigned. 

An endeavor is now being made to adopt the following death cer- 
tificate throughout America. 



RETURN OF A DEATH 

IN THE CITY, TOWN, OR TOWNSHIP OF 



Physician's Certificate. 



1. Full Name of Deceased, 

olor 

3- Sex, 

4. Single, Married 



f Chinese, 

State if < Japanese, 
( Indian. 



("Widow, 
State if ^Widower. 
(Divorced. 



( Years 

\ ' m , , Date of 

' A 8M Months 6 ' Death. 



lay, give hours 1 



\: 



Month. 
Day, . . 



No Certificate will be accepted 
which is MUTILATED, ILLEGI- 
BLE, INACCURATE, or any por- 
tion of which has been ERASED, 
INTERLINED, CORRECTED, or 
ALTERED, as all such changes im- 
pair its value as a Public Record. 



Chief, 



e of I )eath, 



I Contributing, 



1 ' not 

■>/■ <se 

i of 
Health. Should the 

' ' be Re iidence, 

■ rked" Duplica 



M.D. 



CHAPTER XXIX 

LITERATURE 
Post-mortem References 

Adlek. X. Whether post-mortem examinations under any circumstances should 
be allowed in the Jewish Hospitals. The Occident. June, '1856, v . XIV, n. 3.— 
Administration des hopitaux et les autopsies. Arch. gen. de mid., 1842, v. I, 
P- JM- — Albers, J. F. H. Bericht. iiber 84 Leichenoffnungen. Deutsche Klinik, 
1850. v. II. p. 413. — Allen, H. Synopsis of autopsies made at Lincoln General 
Hospital. Proc. Path. Sec. of Phila., 1864, v . II, p. 160.— Allison, H. E. On a 
general system of reporting autopsies in American asylums for the insane. Am. 
J. Insan., 1889-90. v . XLYI, p. 216. — Amano, F. Zusammenstellung der Resultate 
von der letzen 100 Sektionsfallen nebst einigen interessanter Befunden. (Japanese 
text.) Okayama Igaku Kwai Zasslin, 1898, p. 67; p. 102. — Ames, D. Brief notes 
on the conduct of post-mortem examinations. Baltimore, 1897 — AMMANN, P. 
Oratio de autopsia medica. Lipsiae, n. d. — Amon. Zwei Sectionen aus der 
Privatpraxis. Munchen. med. JVcIuischr., 1895, v . XLII, p. 1183. — Autopsies 
cadaveriques des rois de France. C Unique, 1829. v . I, p. 136. — Autopsies at the 
Leichenhof, Vienna. Med. Times and Gaz., 1872, v . II, p. 605. — Azevedo, N. 
Technica d'autopsias clinicas. Med. contemps., Lisbon, 1903, v. XXII. , p. 177. 

Baader, J. Observationes medica? incisionibus cadaverum anatomicis. Sande- 
fort's Thesaurus disscrtationum. Lugd. Batv., 1778, v. III. — Babes, V. Post- 
mortem examinations with a view to bacteriological research. Arch. roum. de 
med. et cliir., Par., 1887, v. I, p. 157. — Baetexs, H. J. Dissertatio medico-legalis 
de oecisi hominis cadazrris inspectione, a inde renuncianda lethalitate. Par., 1808. 
— TBaxdouix. M. Les autopsies dans les hopitaux. Gaz. med. de Par.. 1901, v. 
XII, p. 1. — Barez. Leichenoffnungen. Wchnschr. f. d. ges. Heilk., 1897, v. II, 
p. 102. — Beale, L. S. Suggestions for taking cases and for making post-mortem 
examinations. Lond., 1867 — Beatsox t , W. B. Precis of medicolegal post-mortem 
examinations in Dacca during the year 1865. Indian M. Gaz., 1866, v. I, p. S_\ 
— Bexeke. Zur Technik der Oberkiefer und Nasenhohlensection. Centr. /'. allg. 
Path, und path. Anat., Oct. 25, 1896; Zur Technik der Bauchsection, ibidem, 1900, 
v. II. p. 433. — Bericht der vom V. deutschen Aerztetag gewahltcn Commission 
fur Herstellung der Vorarbeiten zur Einfuhrung der allgemeinen Lcichcnschau in 
Deutschland. Acrztl. Vereinsbl. f. Deutsch.L. 1878, v . VII, p. 3.— Berliner, P. 
Plasti-che Reproduction path. -anat. Praparate. D. med. IVchn., 1892 — Bertrand, L. C. 
Quclques faits d'anatomie pathologique. Par., 1837 — Bierm wi;r. Bericht iiber die 
Leichenoffnungen, Med. Jahrb. d. k. k. bsterr. Staates, 1816, v. Ill, p. y^. — Bill 
to provide for inquests under national authority. Washington, 1886 — BLACKBURN, 
I. YV. A manual of autopsies designed for the use of hospitals for the insane and 
other public institutions. Phila., 1892; Infercrunial Tumors among the Insane. A 
rt of 1612 autopsies in cases of mental disease. Washington, 1903. BLEICH- 

■. Die Funktionspriifung der Mitralklappe bei der Herzsektion. Virch 
1902. v. CLXIX. — Blumer, G. Examining and recording pathological 
material. Albany M. Ann.. 1902. v. XXIIL— Boileau, J. P. H. — Gravimetry in the 

with auto] 
Med. and Surg. Rep. Post. City Hasp., 1877, p. 270.—B0LL] - Atlas und 

Gruudriss der pathologischen Anatomie. Munchen, 1901; Beitrdge cur patholo- 
gischen Anatomie. Y 1903; Arbeiten aus dem pathologischen Ins tit ut zu 

hen. Munchen, 1886; Bericht iiber di< Ehungen im pathologischen 

Institut v. 1 Ann. d. stadt. allg. Krankenl 

hen, 1901. v. XL p. 352 . T. Sepulchre/urn sire anatomia practica ex 

cada- 1700.— B00D mortem observations 

on the appendix. Bull. Iowa Inst.. 1903. v. V, p. viu.i. and I'. Ki 

Manuel de technique des autopsies. Par. 1885. Bowditch, 11 1*. On the 
collection of data at autopsies. Boston M. and S. J.. 1882. v. CVII, p. 
Boyd. Post-mortem appearances in 75 cases. Edinb. M. and S. /., 1841. v . I.V, 

_; — Breslai " ' 'hodc der Eroffnung der Schadelhohle an 



POST MORTEM EXAMINATIONS 

den Leichen Neugeborner. Wicn. mcd. Wchnschr., 1862, v . XII, p. 145.-— Briche- 
11 at. Ouverture cadaverique. Diet. d. sc. med. Par., 1819, v. XXXVIII, p. 552. 
UK. I fctude statistique de 716 autopsies. Arch. gen. de mcd., 1901, n. s., 
\ \ I. p 76 Bri miii, L. Lettera sopra il suo nuoro rachiotomo e stil metodo 
di aprire lo speco vertebrate adottato dalla scuola di anatomia patologica in Padova. 
mcd. itai, prov. venetc. Padova, 1863, v. VI, p. 133. See also Scuola di 
anat. patol. d. r. I r niv. di Padova, 1878. La tannissasione dci tcssuti animali . . . 
dai patologhi. Padova, 1888. — Buchner, L. Sectionsbericht iiber 145 Leichen- 
oflfnungen. Arch. /'. path. Anat., 1859, v . XVII, p. 343. — Buhlig, W. H. General 
and special methods in the post-mortem examination of the brain and spinal cord. 

land M. J.. 1904. v . III. p. 28.-— Bullard, W. N. The importance of well 

made and accurately reported autopsies in the determination of the etiology of 

weak-mindedness and idiocy. /. Psycho- Asthenics. 1903-1904, v . VIII, p. 11. — 

\ E. Vutopsies. Med. Sentinel, Portland, Oregon, 1896, v. IV, p. 244. 

Bl RT, S. S. Diagnosis in the light of a necropsy. Postgraduate, N. Y., 1900, 

\\. ]>. 1092.- Bush, M. J. and Brandts, J. G. Rapport sur le resultat d'au- 

topsies cadaveriques. Biblioth. mcd., Brux., 1827, v. IV, p. 64. — Busse, O. Das 

sektions-Protokoll Berlin, 1903. 

Cadaver in volume II of the Index Catalogue, 1898, will be found to contain 
some additional post-mortem references. Carpenter, I. L. On Autopsies. Tr. X. 
Hampshire M. Soe., Concord, 1897, p. 220. — Carrington, R. E. Notes on Pa- 
thology. ./ handbook for the Post-mortem room. London, 1892 — Cassebohm. 
J. F. Methodus secandi et contemplandi viscera hominis. Halcc, 1740. — Cattell, H. 
W. Some special points on the performance of autopsies on the new-born. Ann. 
Gyneec. and Pcediat., 1892, v. VI, p. 758: Some practical post-mortem points. 
Phila., 1893; Notes on the demonstrations in morbid anatomy, including autopsies. 
Phila., 1893; Post-mortem pathology. Phila., 1903.— Cattell, T. The precau- 
tionary measures which may be employed in dissections and post-mortem exami- 
nations Lancet, Loud., 1847, v. I, p. 645. — Caudereau. Sur un procede nouveau 
de dissociation des glandes. Compt. rend. Soe. de biol., 1879, v. I, p. 291. — 
Cautions for the pathological anatomist. Med. Mag., Bost., 1834, v. VII, p. 491. 
— C. E. I >e l'importancc des autopsies pour les families. Lyon med., 1878, v. 
XXVII, p. 169. — Cerebrotome du Dr. Gavoy. Compt. rend. Soe. de biol., 1885, 
\. II. p. 114. — Cerxe. Une salle d'autopsie. Normandie med., 1891, v. VI, p. 
369. — C11 aille, S. E. Post-mortem changes versus ante-mortem lesions. N. Orl. 
M. and S. /.. 1873-1874, n. s., v . L, p. 639. — Chi art,, H. Pathologisch. anatomische 
Sektionstechnik. Berl., 1894. — Clarke. J. J. Post-mortem examinations in medico- 
legal and ordinary cases. Lond., 1893. — Clement, A. W. Veterinary post-mortem 
examinations. New York, 1891 — Cocks, W. P. Forms for facilitating the records 
of post-mortem appearances. Lond., 1832; Pathological anatomy of the liver, 
spinal cord, and the membranes. (With cases. — Morbid appearance.) Lond., 
1831. CONNELL, W. T. Some post-mortem notes. Kingston M. Quart., 1898-1899, 
v. Ml. p. 172. — CoPLIN, W. M. L. Manual of pathology, including bacteriology, the 
technique of postmortems and methods of pathological research. Phila., 1900. — 

cilman, W. T., and Mallory, F. B. A study of the lesions in selected 
autopsies. Med. and Surg. Rep. Bost. City Hosp., 1896, p. 216.— Cox, G. W. 
Some practical post-mortem points. Indian M. Rec, 1898, v. XV, p. 47. — Craw- 
Post-mortem examination on Mr. Crawford. (N. n., n. d.)— - Cruse, P. 
Obduktionsbefunde nach den Protokollen des Dorpater pathologischen Institut. 
Dorpat. mcd. Ztschr., 1871, v . I, p. 255. 

Dal AND, J. A new post-mortem case. Tr. Path. Soe. Phila., 1898, v. XVIII. 
p. 482. — DALTON, J. C. A ready method of making brain sections for post-mortem 
examinations. Boston M. and S. J.. 1880, v. CIV, p. 57. — Dalton, N. Report 
ol the pathological department ; Analysis of post-mortem examinations per- 
formed from October r. [896, to September 30, 1897. King's Coll. Hosp. Rep., 
I.ond.. 1898, v. I V. p. 273; Report of the pathological department; 
Analysis of post-mortem examinations performed from October 1, 1895, to Sep- 
tember 30, [896. Ibid., 1895-1896, Lond., 1897, v . Ill, p. 251.— Daniels, C. W. 
es of postmortems made in the Public Hospital, Georgetown, from 
April 1 to December 31, 1893. Brit. Guiana M. Ann., Demerara, 1894, v . VI, p. 

Further notes on a scries of postmortems in the Public Hospital, George- 

. April. [893, to March, 1895. Ibid., 1895, p. 50. — Davy, J. On a new method 
of preserving anatomical preparations for a limited time. In his: Researches Phys. 
and Anat., Lond., 1839; Some directions for making and keeping anatomical 



POST-MORTEM REFERENCES 467 

preparations in hot climates. Ibid. — De Angelis, M. (i. Tecnica d. autopsie. Milan, 
1893 — Degranges, E. Souvenirs de la cour d' assises de la Gironde. Union med. 
de la Gironde. 1863, v. VIII, p. 401. — Delafield, F. A hand-book of post-mortem 
examinations and morbid anatomy. New York. 1872. — Demme, T. A. A de- 
scription of a craniotome tor post-mortem examinations. Med. and Surg. Reporter, 
1860. v. IV. p. 295. — De Rvckere and Corin. A quel moment est-il permis an 
medecin legiste de pratiquer l'autopsie? Ann. Soc. do mod. leg. de Belg., Charle- 
roy, 1900-1901. v. XII. p. 126. — Dezeimez's Autopsy. Pis. report, do me de cine. 
Par.. 1834. v . VI, p. 160.— Douglass, S. H. Method of conducting post-mortem 
examinations in cases of suspected poisoning. Perins J. M., Ann Arb., Mich., 
1853-1854. v. 1. p. 40. — Dowler, B. Post-mortem researches, IPcst. J. M. and S.. 
Louisville. 1843. v. VII, p. 24T : v. VIII, p. 241. — Dubixi. A. Una parola stii falsi 
risultati che si ottengono dalle sezioni cadaveriche incomplete. Gaze, mod., Milano, 
1845. v. IV. p. 197; Dell' arte di fare le sezioni cadaveriche. Ibid., 1847, v. VI. 
p. 319. — Duchaussoy. Surprises que certaines autopsies nous reservent. Bull. Soe. 
de med. prat, de Par., 1891— Dwight. The inquest. Med. Roe., 1879. 

Eckard. E. How to conduct an autopsy. Peoria M. /.. 1896, v. I, p. 344. — 
Eisexlohr. L. Bericht fiber 3749 wahrend der Jahre 1878-84 im Pathologischen 
Institut zu Munchen vorgenommene Sectionen. Arb. a. d. path. Inst. zu Munchen. 
Stuttg.. 1886, p. 462. — Excel. Methode bei Leichenuntersuchungen. Wien. med. 
Wchnschr., 1870. v. XX. p. 1093; Aus der Leichen-kammer der k. k. Josef's 
Akademie. Spitals-Ztg.. Wien, 1864, p. 209; Scctions-Beschrcibungen. Wien, 
1861; Sectionsergebnisse an der Prager pathol-anatomischen Anstalt vom Oct. 1, 
1849-Feb. 1. 1850. Vrtljschr. f. d. prakt. Heilk.. Prag, 1850, v. XXVII, p. 0: 
Darstellung der Peichenerscheinungen und dcrcn Bedcutung. Wien, 1854; Die 
Bestimmung der Blutmenge bei Leichenuntersuchungen. Wchnbl. d. Ztschr. d. 
k. k. Gesellseh. d. Aerzte. Wien, 1866, v. XXII, p. 341.— Erichsen, J. Bericht 
uber die im Hebammeninstitut, Hirer Kaiserlichen Hoheit der Grossfiirsten Helena 
Pawlowna ausgefuhrten Sectionen fur die Jahre 1862 und 1863. St. Petersb. mod. 
Ztschr.. 1865. v. VIII, p. 257. — Escolar, S. Extracto del resultado de las necro- 
-cqpias practicadas en el mes de agosto en la sala de Santo Domingo del hospital 
general de este cortc. Bol. de med., drug, y farm.. Madrid, 1850-1853, v. V. 

Fabricius. P. C. Mcthodus cadavera humana rite sccandi. Halac and 
Helmstadii\ 1774; De autopsiae in medicina ntilitate ct praestantia. Helmstadii, 
1784.— Fearx. J. R. Post-mortem Revelations. Calif. M. /., 1896, v . XVII. p. 
243. — Feldmaxx, J. The relations of practising physicians to pathological post- 
mortems and the cjuestion of prosecution in our country. Gyogydszat. Budapest, 
1902. v. XLII, p. to. — Fexger, C. Beretning 0111 422 Sektioner. Nord. med. .Irk., 
Stockholm. 1873. v. V, No. 18. — Fere. Procede de coup du crane. Progres med.. 
1877. v. V, p. 495. — Finlayson, J. Method of performing post-mortem examina- 
Clin. Diagnosis. Phila.. 1878 — Fixnell. Post-mortem cases. Med. Pee., 
1869. v. IV, p. 260. — Fleischmann, D. G. Leichenoffnungen. Rcpert. f. d. ges. 
Med., Jena. 1842. v. A", p. 273. — Fleming, R. A. Experience gained from post- 
n relation to the practice of medicine and surgery. Internat. Clin.. 
1902. 12th S.. v. II, p. 142. — Fochier, A. Le droit aux autopsies dans les hopitaux. 
med., 1878. v. XXVII, p. 287. — Fodere, F. hi. Regies de ['autopsies cadave- 
rique des blesses. Diet. a. so. med.. Par.. 1820, v. XLIII, p. 119.— Form of record 
of autopsy. CJ. S. War Department. Surgeon-General's Office. Washington, 1882. 
— Forster, A. Uebersicht von 639 in den Jahren [849 56 verrichteten Sektionen. 
Schmidt's Jahrb., 1858. v. XCVII, p. 89; Fortsetzung der Instruction fur die 

•lichen angestellten Aerzte und Wundarzte in den k. k. (Esterreichischen 
Staaten wie sie -ich bei gerichtlichen Leicbenbeschauen zu benehmen haben. Wed. 
Jahrb. d. k. k. osterr. Staates. Wein, 1816, v . 111. p. 17.- -Friedrek ii, X. Uber den 
werth der Leichenoffnungen. liphem. d. Heilk., Bamb. and Wiirzb., 1814. v . 
VIII, p. t,?,?,: Werth der Leichenoffnungen /\\v Bestimmung Typhus und Him 
, sammelte med. Progr., Wiirzburg, 1824. ,,. 38.. Fuchs, C. II 
Leichenoffnungen. Heidelb. klin. .Inn.. 1833. v. IX. p. 51 Bericht 

bis zinii r Jan., 1854 zu Jena angestellten Leichenunter 
Michungen. Deutsche Klinik, 1854. \. VI, p. 181. 

Tjairdnek. W. T. Suggestions in regard to the performance of p<<-t mortem 

examinations. Edinb. M. and S. P. 1854, v . LXXXI, p. 302.— Gannet. Posl 

mortem examination-. Reference Handbook of the Medical Sciences, X. V . 1887, 

v. v.— G.\t-ster. Rflckblick auf di( Leichen obduktionen, Ztschr. d. k. k. 

ch. d. Aerzte zu Wien, 1855, v. IT, p. 257.— GenersK h. A. A/ [900 ik 






POST MORTEM EXAMINATIONS 



ibyaman a Szt 1st van ECoihazban vegzett bonczolasok koziil nehany. Buda- 

■'■. 1900 1901. p. 2~ ) q. — Genoves, J. Breve resefia sobre la 

le importancia de la inspection cadaverica. Bol. de med., drug, y farm., 1849, 

\ IV, p. 250.- Gerber, B. 1\. De legitima cadaveris occisi sectione occasione art. 

■ K 1 >.. 1781. — Gericke, P. Pr. quo inspectionem cadaveris in homocidio 
apud itm in usu fuisse ostein! it simulque publicas scctiones et demon- 

cadaveris foeminini. Helmstadii, 1739; Programma in quo inspec- 
laveris in homicidio apud Romanos olim in usu fuisse ostenditur. 
Helmstadii, 1738.- Gerlach, L. LJeber ein neues Verfahren, kleinere anatomische 
l! Zwecke zu fixiren und zu conserviren. Sitsungsb. d. phys.-med. 
long., 1881 — Gianturco, V. Mauuale della tecnica delle auto p sic c delta 
a anatoma pathologica. Napoli, 1890 — Gilbride, J. J. A simple method 
closing the body after an autopsy. Am. Med., Phila., 1902, v . IV, p. 768. — 
eber Leichenobduction. Ztschr. f. Nat. u. Hcilk. in Ungarn., 
1851 52. v. II. p. t. — Goubert. Manuel de I'art des autopsies cadaveriques. Par., 
1867.- Grainger, T. Analysis of the post-mortem examinations in the Murstrida- 
listrict during the past five years. Indian M. Gas., 1902, v. XXXVII, p. 303. 
NDJUX. Les autopsies a la guerre, a la marine et aux colonies. /. de Med. 
■r., 1901, v. XIII, p. 239. — Graupner, R., and Zimmermann, F. Technik 
und Diagnostik am Sektionstisch. Zwickau, 1899. — Greding, J. E. De cadaveris 
inspectione sive sectione legali. Jena, 1742 — Green, C. R. M. Return of sudden 
deaths requiring coroner's inquests for five years (from 1896 to 1900) in the city 
ilcutta. Indian M. Gas., 1902, v. XXXVII. p. 301.— Green, W. A. Synopsis 
of symptoms and post-mortem appearances in six cases of fever; in five cases of 
cholera; in two cases of death from exposure to the sun; in one case of death 
from drinking. 7V. M. and Phys. Soc. of Bengal, Calcutta, 1838-1840, p. 23. — 
\ field, W. S. Jottings from the post-mortem room. St. Thomas Hosp. Rep., 
Lond., 1875. v. VI, p. 239. — Griesinger, W. Uber die Untersuchungs-Methode des 
Schadel Inhaltes. Arch. f. Psychiat.. 1868, v. I, p. 317. — Guiteras, J. Notes upon 
the lectures on general pathology. Phila.. 1890-1891 — Guntz, E. W. Der Leich- 
nani des Ncugebornen in seincu physischen Verzvandlungen nach Beobachtungcn 
und Versuchen dargcstcllt. Leipzig, 1827. — Guyot, C. De cadaverum sectionibus 
pathologicis. et recto ex illis ferendo judicio. Groningae, 1818. — Gvozdeff. I. 
Pirst external examination of the cadaver of a grown individual. Kazan, 1887. 
RAND. Obductionsbericht und Gutachten uber die Ursache des Todes 
eines bald nach einer erlittenen Misshandlung. Verstorbenen. Arch. f ; med. 
Erfahr, Berl., 1818, v. II, p. 167. — Hauck. F. H. G. De autopsies conditionibus. 
Halis, 1836 — Hartmann, R. Rede iiber die Mcthode des Unterrichtes in der 
Anthropotomie. Berl., 1873 — Harris, R. O. Autopsies and physical examina- 
tions. Boston M. and S. /., 1900, v . CXLIII, p. 420. — Harris, T. Post-mortem 
Handbook for Clinical and Medico-legal Purposes. Lond., 1887 — LIarke, Theod. 
Section der oberen Athmungswege. Berl. klin. Wchnschr., July 25, 1892; 
Ein neues Verfahren die nasen Rachcnhbhle mit ihren pneumatischen Anhdngen 
am Lcichnam ohne dusserc Entstellung freizulegen. Virchozv's Archiv, 1891, p. 
125, pt. 2; Athmungswege Sectionstechnik. Ccntralblatt filr Pathologic, 1893, v. 
IV, p. i/O-— Hamilton*, D. J. A textbook of pathology. Chap. I, v. I (Sectio 
»nd. and New York, 1889 — Haller, A. Pathological observations 
treating chiefly of dissections of morbid bodies. Lond., 1756 — Haines, W. D. 
mortem examinations. /. Am. M. Ass., 1903, v . XL, p. 442. — Hebb, R. G. 
Report of post-mortem examinations made in 1887. Westminst. Hosp. Rep., Lond., 
1888. v. IV, p. 175; Report of the postmortems made in 1897. Ibid., 1899, v. 
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POST MORTEM EXAMINATIONS 



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ferences marked with a * have not been verified.) 



GLOSSARY INDEX 



¥¥ 

(The Roman numeral letters refer to chapters; the Arabic numerical figures to 
pages. Cross-references are frequent, and explanatory notes will be found inserted 
here and there.) 



A 

Abdomen, enlargement of veins of, 61 

injecting embalming fluid through, 

286 
regional landmarks of; epigastric, 
umbilical, hypogastric, right and 
left hypochondriac, right and left 
lumbar, and right and left iliac, 
stria; of, 61 
Abdominal cavity, abnormal contents of. 
20. 8^.' 86. 88, 89 
bile in, 86 

discission of, in animals, 383, 393 

diseases of organs of, x, p. 159; 

xi. p. 199; xii. p. 213; xviii, p. 

2/5 
examination of, 88, 90, 91, 161, 
162, 167, 275, 438, 439, 440, 442. 

443 
exposure of, in animals. 375 
exudates in, 86 
fluid in, 85 
foreign bodies in. 88 
free bodies in, 20, 88 
in anthrax, 292 
incision, closure of. 285 
organs of. critical examination 

of, x. p. 159 
removal of organs of, 91. 442 

from animals. 378.391,393 
superficial examination of organs 

of, vi, p. 79; xxvii. p. 440 
surgical instruments in, 88 
technic of opening, vi, p. 79; 

xviii. p. 275: xxvii. p. 440 
topographic examination of or- 
gans in, vi. p. 79: xviii. p. 275; 
ii. p. 440 
transudates in. 86 
hernia. 90 

incision, method of closing, 285 
muscles, post-mortem rigidity of, «>] 
organs condition of. in cholera A-iat- 

ica, 293 
pregnancy, see Pregnancy, extra- 
uterine. 
sympathetic-. 14 
tubercul 7 i2 

typhus, see Typhoid f< 



Abnormalities, see Malformations and the 

organs themselves. 
Abortion, causes of, 303, 406 
criminal, 406 

abscess of lung following. 147 
history of a case of, 279 
Abrachius, upper limbs absent, lower 

limbs well formed. 
Abrasions in skin of hands, how detected, 

38 
Abrine, toxicology of, 421 
Abscess, actinomycotic, 290 
amoebic, of liver. 174 
appendiceal, 171 
as a cause of death, 408 
cold, 311 

embolic, of lung, 147 
metastatic, of heart, 130 
multiple, of liver, 219 
of bones, 268 
brain, 246 
liver, 159, 213, 219 
lungs, 147 

multiple, 147 
solitary, 147 
oesophagus, 190 
prostate, 212 
psoas muscles, 198 
testicles. 21 1 
perinephritis 203 
periurethral, 297 
retropharyngeal. 292 
subdiaphragmatic, 159 
subphrenic. 159 
vaginal. 21 1 
Absence of anus, 
clitoris, 69 
hymen. 69 
kidneys, 199 
nos< . 
peni 

sternum, 68 
urethi 
Absorbent cotton, use of. in preservation 

of body, 283 
Absorption in pneumonia, 153 

of deleterious gases, 463 
Acardia, 113 
\r.'iru<- scabiei, 320 
32 4*9 



490 



INDEX 



Accessor] adrenals, 17^ 

kidneys, [on 

livers, 204, 367 

lung-tissue, 91 

pancreases, 220 

sinuses, exposure of, in animals, 389 

spleens, [62 

thyroid glands, 90 
Accidental submersion, 463 

traumatisms, 463 
Accidents of pregnancy, 247, 460 

puerperal, 4<> n 
Acephalus, 67 

Acetic acid as a fixing fluid, 329 

toxicol* igj of, 4-7 
Acetone, in diabetic urine, 222 
Acholia, deficiency or absence of the secre- 
tion oi bile. 
Achorion Schonleinii, Plate V, No. 9, 

facing page 350 
Acid, acetic, as a fixing fluid, 329 
ti 'xicology of, 427 
beta-oxybutyric, in diabetes, 222 

toxicology of, 421 
boric, toxicology of, 429 
carbolic, effect of, on skin, 65 
on urine, 425 
toxicology of, 421,422,423,425,426 
chromic, as a fixing fluid, 330 
chromo-acetic, as a fixing fluid, 331 
chromo-aceto-osmic, as a fixing fluid, 

33i 
chromo-formic, as a fixing fluid, 331 
chromo-nitric, as a fixing fluid, 331 
chromo-osmic, as a fixing fluid, 331 
corrosive, toxicology of, 421, 423, 424, 

4-'5 
diacetic, in diabetes, 222 
filicic. toxicology of, 421 
helvellac, toxicology of, 423, 425 
hydrochloric, toxicology of, 422, 427 
hydrocyanic, toxicology of, 50, 421, 

4 -'5. 430 
hydrofluoric, toxicology of, 422 
nitric, as a fixative of tissue, 336 

toxicology of, 422. 423, 427 
osmic, a- a fixative of tissue, 336 
toxicology of. 422 
;lic. toxicology of, 424, 426, 427 
^butyric, toxicology of, 421 
parabanic, toxicology of, 424 
picric, as a fixative, 237 

toxicology of. 423, 424 
pirro-acctic. as a fixative, 237 
pyrogallic, in study of anaerobic bac- 
terid . 
salts of metals, toxicology of, 424 
sulphuric, toxicology of, 426 
sulphurous, toxicology of. 422 
uric, in calculi, 207 
Adds, corrosive, toxicology of. 421, 423 
effect of. on skin. 65. 426 
mineral, toxicology of. 424. 426 



Acids, organic, employed as fixing fluids, 

329 
vegetable, toxicology of, 426 
Acne, 62 

of vulva, 69 
Aconite, toxicology of, 411, 427 
Aconitine, toxicology of, 421, 422 
Acquired anomalies and deformities, 17, 

19, 72 
Acrodynia, 351 
Acromegaly, 223, 246 
cause of, 70 

thymus gland present in, 95 
Actinomycosis, 290, 373 
abscesses in, 290 
in peritoneum, 159 
of alimentary tract, 290 
appendix, 171 
brain, 246, 255 
heart, 134, 290 
lungs, 290 
skin, 290 
thorax, 290 
primary lesion of, 290 
synonyms of, 449 
Acute, see the diseases themselves. 
Addison's disease, 16, 180 
cause of, 181 
complications of, 452 
Adenitis, mediastinal, simple, 146 
suppurative, 146 
tuberculous, 146 
Adenocystomata of kidney, 220 

liver, 220 
Adenoids in chronic nasal catarrh, 141 
Adenoma of bladder, 205 
ciliary body, 75 
intestines, 171 
liver, 220 
lungs, 155 
ovary, 209 
Adhesions, 20, 87, 195 
Adhesive pericarditis, 144 
Adipocere, 46, 49 
Adiposis dolorosa, 59 

Administration of poisons, symptoms ob- 
served after, 421 
Adonis, toxicology of, 424 
Adrenals, 175 

aberrant, 204, 220 

accessory, 179 

atrophy of, 180 

color of, 180 

dimensions of, 369 

disease of, 16, 60, 180, 181, 324 

examination of, 14, 15, 175, 179, 180, 

276, 442 
fixatives for, 340 
measurements of, 369 
miliary tubercles in, 180 
removal of, 15, 176, 180, 280 

in animals, 381 
situation of, 179 



INDEX 



49 1 



Adrenals, tumors of, 180 

weight of, 369 
Adynamic fever, see Typhoid fever. 
yEstivo-autumnal malaria, 322 
Affections, see the various diseases. 
Agaricus bulbosus, toxicology of, 423 
—Age, 55. 215 

apparent, 55 
estimation of, 55, 58 
real, 55 
Agglutinative reaction, 118 
Ague, see Fever, malarial. 
Air emboli, method of discovering, in tho- 
racic cavity, 100 
embolism of lungs, 148 
Air-cells, hemorrhage into, 148 
Air-passages, diseases of, ix. p. 141 
exposure of, 256 
examination of. xvi, p. 256 
foreign bodies in, 146 
Albinos, hair of. 76 
Albuminous degeneration, fixative for, 338 

periostitis, 271 

Albuminuria in erysipelas, 295 

pregnancy, 448 

scarlatina, 448 

smallpox, 448 

Alcohol as a fixing thud. 330, 2>37^ 33% 

preserving fluid. 327, 328, 342, 343 
toxicology of. 421. 423, 427 
Alcoholism. 427 

as a cause of abortion, 407 
cirrhosis of liver due to, 216, 427 
delays post-mortem rigidity, 51 
gastritis due to. 427 
gastro-intestinal tract in, 427 
genito-urinary tract in, 427 
nervous system in, 427 
synonyms of. 452 
toxicology in, 421 
vascular system in. 427 
Alimentary tract, measurements of, 366 

suspicious undissolved foreign 

bodies in, 418 
tuberculosis of, 312 
Alkalies, toxicology of, 421, 424. 4^7 
Alkaline carbonates, effect on urine, 424 
Alkalinity of gastric contents, 418 
Alkaloidal poisons 421 
Alkaptonuria, 223 
Alum hematoxylin. 341 
Alveolar process, absent, 68 

deformities of. 68 
Amanita phalloides. 418. 424 
Amanuen-is at postmortem, 22 

duties of. 22 
American Anthropometric Society, 4 

insurance standard of weight, 358 
Ammonia, to remove iodin stains, 286, 421 
toxicology of, 19. 21. 411. 42 T, 422, 423 
use of. by injection, as a sign of 
death. 47 
Ammoniaemia, effect on urine. 424 



Ammonium urate, 207 

Amoeba coli, method of fixing, 338 

Amoebic abscess of liver, 174 

dysentery. 173. 219 
Amputation, complications of, 462 

muscular twitchings in limbs after, 47 
of hand in spreading gangrene, 45 
synonyms of, 461 
Amussat's hammer, 243 
Amyl nitrite, toxicology of, 21, 423, 425 
Amyloid degeneration. 129, 307, 418 
fixatives for, 338 
of arteries, 135 
kidney, 199 
liver, 214 
spleen, 164 
reaction, 179 
Anaemia, blood changes in, 122 
causes of, 116 
cerebri, 247 
definition of. 116 
essential, 116 
idiopathic, 116 
von Jaksch's, 124 
of brain, 247 

lungs, 148 
pernicious, 121, 195 
primary, 116 

progressive pernicious, 121 
secondary, 116 
simple, 116 
splenic, 123 
symptomatic, it6 
synonyms of, 452 
varieties of, 116 
Anaemic infarcts of kidney, 201 

spleen, 163 
Anaerobic growth, Wallis's method for, 
349 
methods, 352 
organisms, 349 
Anaesthetic form of leprosy, 299 
Anatomical board, 5 

warts, 318 
Anatomy, morbid, see diseases of, under 
the various organs. 
Study of, at postmortems, 3 
Anchylostomum duodenale, 121, 321 
Anencephalus, 67 
Aneurism, 137 

anastomotic, [38 
arteriovenous, 130 
by distention, [38 
erosion, 138 

rupture. 138 

cirsoid, 138, [40 
conditions associated with, 138 
congenital, 139 

contour of blood \ es <-1 - in, 18 
cylindrical, F38 
death from, 407, 408 
deformity due to, 72 
■ cting, 138 



492 



INDEX 



Aneurism, endothelial lining of, 130 
etiology of, [39 
false, 137 

femoral, mistaken for hernia, 139 
fibrous clot of, [38 
fusiform, [37 

gluteal, mistaken for abscess, 139 
hernial. 137 
infective, [38 
miliary. [38 
mycotic, [38 

of animals, 383 

aorta, method of removing, IOO 

bones, 274 

carotid mistaken for sarcoma, 138 

cerebral arteries. 247 

heart. 130 

location of, 130 
sinus of Valsalva, 131, 138 
pathology of, 138 
rupture of, as a cause of death, 138, 

139 
saccular, 138 

treated by wiring and electrolysis, 
139 
seats of, j 39 
spurious, 137 
syphilitic, 308 
traction, 138 
traumatic, 138 
true. 137 
varieties of, 137 
Angina pectoris. 129, 455 
Angioma of arteries, 137 
bone, 273 
brain. 255 
iris. 75 
kidney. 204 
liver. 220 
spleen, 164 
tonsil^, 143 

ma of nasal passages, 141 
Angular method of removing the calva- 

rium. 226. 227 
Anhydrremia. ri6 
Anideus, 67 
Anilin blue as a stain. 341 

colors, effect on urine, 425. 426 
toxicology of, 421, 422, 423, 425, 426 
yellow, toxicology of. 422 
Animal poisons, 421 
AnimaN. aneurism in, 383 

domestic, contagious diseases from, 

373 
inoculation of. 353. 354 
intraperitoneal inoculation of. 354 
intravenous inoculation of, 354 
irritant poisons, 421 
lower, value of necropsies upon. 373 
method of cutting ribs of, 377 
methods of killing for post-mortem 

examinations. 374 
most used for inoculation. 353 



Animals, post-mortem examination of, 
355, xxv, p. 373 
preparation of, for inoculation, 353 
removal of extremities of, 375 

hide of, 375 
site of inoculation in, 354 
subcutaneous inoculation of, 354 
taking temperature of, 353 
toxinic poisons, 421 
weight of, 353 

where and how to be killed for ne- 
cropsy, 374 
Animation, suspended, 46 
Ankylosing arthritis, 264 
Ankylosis, 71, 263, 264, 267 
congenital, 267 
false, 267 

mistaken for post-mortem rigidity, 52 
of cricoarytenoid joint, 143 
traumatic, 71 
Ankylostoma americana, 170 
caninum, 170 
duodenale, 121 
Anomalies, 17, 19, 70 

congenital, of brain, 249 
cord, 249 
heart, 113 
liver, 220 
nails, 77 
pancreas, 220 
Anopheles mosquitoes, as cause of ma- 
laria, 322 
Anterior poliomyelitis, 351 
Anthracosis, 16, 155, 216 
Anthracotic cirrhosis of liver, 217 
Anthrax, 291, 373, 449 
of abdomen, 292 
brain, 292 
kidneys, 292 
spinal cord, 292 
thorax, 291 
spores of, long lived, 356 
Anthropometric Society, American, 4 
Antifebrin, toxicology of, 423, 425 
Antimony, toxicology of, 418, 421, 422, 

423, 428 
Antipyretics, 421, 422, 425 
Antipyrin, toxicology of, 422, 425 
Antiseptic dressings for post-mortem 

wounds, 43 
Antiseptics, synthetical, 421 
Antiserum test for diagnosis of human 

blood, 118 
Antrum of Highmore, empyema of, 141 
Anus, absence of, 69 
artificial, 20 
atrophy of, 69 
diseases of, 69, 70, 307, 457 
examination of, 14, 15, 438 
fissures of, 69 
hypertrophy of, 69 
tumors of, 69 
Aorta, abdominal, 4, 139, 197, 365, 442 



INDEX 



493 



Aorta, diseases of, 42, 72, 100, III, 133, 
134. 139, 156, 30/ 
endocardial vegetations of arch of, 

100 
examination of, 14, 15, 105, III, 197 

in animals, 383 
hypoplasia of, 136 
removal of, 15, 100, ill, 197 
in animals, 381, 383 
thoracic, 14, 135, 139, 365 
Aortic valves, diseases of, 129, 133, 135, 
307 
examination of, 103, 104 
measurements of, 103, 365 
Aortitis, 137 
Aparathyroidism, 97 
Aphthae of vulva, 69 
Apncea, 21 
Apodia, 70 

Apomorphine, toxicology of, 424 
Apoplexia neonatorum, 247 
Apoplexy, cerebral, see also Brain, hemor- 
rhage of. 
condition of eye in, 48 
mistaken for alcoholism, 21 
pancreatic, 221 
pulmonary. 456 
Appendicitis. 171, 172 
catarrhal, 171, 172 
follicular, 171 
gangrenous, 172 
infective, 172 
obliterative, 172 
organisms of, 171 
parasites in, 171 
suppurative, 171 
Appendix vermiformis, 171 

articles found in, 171 
diseases of, 165, 171, 290, 299, 411 
examination of, 15, 89, 276, 443 
measurements of, 171, 366 
removal of, 16, 64 
tumors of, 172 

Virchow's dictum concerning, 89 
weight of, 366 
worms in, 171 
Arachnoid, 231, 233, 241, 251, 252, 313 

weight of pia and, 362 
Arecoline, toxicology of, 422, 423, 424 
Argyria, 422 
Arsenic, 418 

detection of, by X-rays, 429 
toxicology of, 411, 421, 422, 423, 4_M, 
425. 426, 428, 429 
Arsenical melano-i = . 42° 

poisoning, accidental, 428 
localization of, 429 
varieties of, 428 
Arseni<-m. 422 
Arseniuretted hydrogen, toxicology of, 

423. 425 
Arterial embalmir:^ 
sclero^i-. 22^ 



Arteries, 129 

amyloid degeneration of, 135 

aneurismal, in tuberculosis, 316 

aneurisms of, 137 

arteriosclerosis of, 134 

atheroma of, 20, viii 

atrophy of, 135 

calcareous infiltration of, 135 

cerebral, aneurism of, 247 

condition of, after death, 47 

coronary, 129 

diseases of, 18, 20, 21, 128, viii, p. 134; 
221, 223, 249, 253, 306, 308, 316, 407, 
411, 431 

examination of, 439, 440 
in animals, 383 

fatty degeneration of, 135 

hyaline degeneration of, 136 

hypertrophy of, 136 

hypoplasia of, 136 

iliac, curvatures in, 20 

inflammations of, 136 

morbid changes in, 134 

pipe-stem, 129 

pulmonary, how distinguished from 
veins, no 

syphilis of, 137 

tuberculosis of, 137 

tumors of, 137 
Arteriosclerosis, 134 

death from, 408 

diffuse, 135 

elastic tissue in, 134 

in aortic incompetency, 133 

nodular, 135 

of penis, 68 

pathology of, 134 

seat of, 134 

senile, 135 

special forms of, 135 

stages of, 134 

syphilitic, 307 
Arteriovenous aneurism, 138 
Arteritis obliterans, 136 
Arthritis, 153, 261, 461 

acute, 261 

ankylosing, 261, 264 

deformans, 136, 262, 265, 266 

fibrinous, 261 

gonorrhneal, 263, 297 

gouty, 26 f, 263 

infective, 26] 

neurogenous, 264 

obliterative. 250 

pneumococcal, 264 

purulent, 201. j^j 

rheumatic, 262, 263. 

scarlatinal, 305 

serofibrinou 

SerOUS, 261 

spinal, 264 
syphilitic, 26r, 264 
. 264 



494 



INDEX 



Arthritis, tuberculous, 261, 264, 265 

ulcerative, 262 
Arthropathies, 248, 26] 
Arthropyosis, 26] 
noids, 73, 143 
iris lumbricoides, 321 
Ascites, associated conditions of, 85 
detection of, 66 
pore, a -pore lying within a special 
sporecase or a -ens, Plate v, No. 12, 350 
Asiatic cholera, synonyms of, 449 
Asomata, 67 

Asparagus, effect on urine, 424 
Aspergillus, 151. 152 
Asphyxia, 21, 415 
suicide by, 462 
Asphyxiation, distention of right heart 

alter. 100 
Assistants, 6, $7 
Asthma, 144, 456 

Atavism, congenital characteristics de- 
rived from remote ancestors. 
Ataxia, hereditary, 248 

locomotor, 248 
Ataxic fever, see Typhoid fever. 
Atelectasis of lungs, 147 

fetal, 147 
Atelectatic bronchiectasis, 144 
Atheroma. 20, 134, 307 
Atheromatous kidneys, 179 
Atony of gastric walls, 191 
Atresia of glans penis, 68 
urethra, 69 
uterus, 209 
oris, 68 
Atrophic bronchitis, 145 

changes in pancreas. 196 
chronic nasal catarrh, 141 
cirrhosis of liver, 216 

shape of ensiform appendix in, 94 
emphysema of lungs, 150 
endometritis, 210 
gastritis. 192 
Atrophy. 70 

acute yellow, of liver, 18, 213 
and hypertrophy in same part, 18 
brown. 129 
cause of, 70 
congenital. 70 
local. 70 
location of, 70 
of adrenals, 180 
anu 

arteries, 135 
bone, 264 
clitor 
finger 
elan- peni 
limbs, 56 

liver, acute yellow, 425 
marrow, 267 
ovary, 209 
scrotum, 69 



Atrophy of testicles, 69, 211, 419 
toes, 68 
tongue, 68 
uterus, 209 
vulva, 69 
progressive muscular, 253 
senile, 129 
Atropine, effect on pupil after death, 46 
toxicology of, 421, 422, 423, 424, 425, 
426, 429 
Aurantia, toxicology of, 422 
Autodigestion, 88 
Auto-intoxication, 413, 419 
Autopepsia, 87 
Autopsy, see Postmortem. 

first use of word, 2 
Autositic monster, 67 
Average height, 358 

weight, 358 
Avoirdupois weight, 357 
Axes, visual, deviation of, 73, 74 
Axillary cellulitis, treatment of, 44 

glands, how exposed, 81 
Axis-cylinders, fixatives for, 339 
Ayer Clinical Laboratory of the Pennsyl- 
vania Hospital, 10 
Azygos veins, 15 

B 

Bacilli, how distinguished from bacteria, 

349 
Bacillus anthracis, 290, 350 

diphtherial, see Corynebacterium diph- 
therise. 

leprae, see Mycobacterium leprae. 

mallei, see Corynebacterium mallei. 

cedematis maligni, 350 

tetani, 350 
Bacteria, cultures of, how prepared for 
inoculation, 353 

effect on urine, 424 

how^ distinguished from bacilli, 349 

in the body, 207 

phosphorescent, 404 
Bacterial spores, longevity of, 356 

toxinic poisons, 421 
Bacteriologic examination, care of instru- 
ments in, 346 
of bile-ducts, 194 
gall-bladder, 194 

investigations, 14, xxiii, p. 346 
Bacterium aerogenes capsulatum, 350 

coli commune, 86, 160, 350 

dysenteriae, 350 

enteritidis, 350 

influenzae, 350 

paratyphoid, 350 

pestis, 301, 350 

pneumoniae, 151, 350 

proteum, see B. vulgare, 161, 350 

pyocyaneum, 41, 42, 161, 350 

rhinoscleromatis, 350 



INDEX 



495 



Bacterium septicaemiae haemorrhagicum, 
350 

typhi murium, 350 

typhosum, 350 

vulgare, 161. 350 
Balsam of copaiba, toxicology of, 422 
Barium salts, toxicology of, 424 
Bark, cinchona, toxicology of, 422 
Barlow's disease, 126, 271 
Bartholinian glands, enlargement of, 69 
Baryta, toxicology of, 424 
Basal ganglia, fixatives for, 339 
Basedow's disease, 97. 147, 258 
Base of skull, examination of, 233 
Basins, enamelled. ^ 
Battery fluid, toxicology of, 8 
Beaded ribs of rhachitis, 72 
Beale's Prussian blue, 345 
Beclard's sign, 278 
Bedbug, 319 

Bed-sores, location of, 66 
Belladonna, toxicology of, 421, 422, 424 
Bellows for inflating viscera, 34 
Bensley's solution for fixing tissues, 335 
Benzaldehyd, toxicology of, 425 
Benzokoll. toxicology of, 425 
Beriberi, 292, 351 

Bertillon classification of causes of death, 
xxviii, p. 448 

system, 53 
Beta-oxybutyric acid, 222, 421 
Bichlorid of mercury as a fixative, 3^ 

effect on urine, 425, 426 
Bichlorid-tablet solution for preserving 

tissues, 326 
Bichromate of potassium, 8, 234, 327, 331 
Bile, 214 

collection of, 193 

composition of, 214 

in abdominal cavity, 86 
blood, 120 
gall-bladder, 195 

pigments, 214 

specific gravity of, 214 
Bile-ducts, bacteriologic examination of, 
194 

congenital absence of common, 215 

diseases of, 194, 195 

examination of, 162, 187, 195, 442 
in animals, 391, 393 
Bilharzia haematobia, 202, 207 
Biliary calculi, ^ee Gall-stones. 
Bilirubin crystals, 120 

infarcts. 201 
Binoxalate of potassium, effect on urine, 

424, 426 
Biologic blood-test, 118 
Biondi-Heidenhain stain, 341 
Bird-, post-mortem examination of, 394 
Bishop, postmortem on, 7 
Bismarck brown, toxicology of, 422 
Bismuth, toxicology of. 423 
Bisulphid. carbon, toxicology of, 421, 422 



Black urine, causes of, 206 
Bladder, adenoma of, 205 

Bilharzia haematobia of, 207 

carcinoma of, 205 

cysticercus of, 207 

dimensions of, 368 

diseases of, 68, 126, 127, 205, 206, 224, 
313, 427, 459 

Distoma haematobium of, 207 

echinococci of, 207 

Eustrongylus gigas of, 207 

examination of, 14, 15, 68, 181 

extroversion of, 68 

fibroma of. 205 

filaria of, 207 

gangrene of, 205 

inflammation of, see Cystitis. 

inversion of, 206 

measurements of, 368 

mixed tumors of, 206 

myoma of, 205 

parasites in, 207 

pentastoma of, 207 

pockets in walls of, 206 

removal of, 184, 442 

in animals, 386 

rupture of, 205 

sarcoma of, 205 

tuberculosis of, 205, 314 

tumors of, 205 

weight of, 368 
Bleeding, see Hemorrhage. 

use of the word in court instead of 
" hemorrhage," 401 
Blenorrhagia of adult, synonyms of, 450 

complications of, 450 
Blister on dead skin, 48 

location of, to be noted, 66 
Blocks of wood as head-rests, ss 
Blood, abnormal constituents of, 120 

appearance of, in poisoning, 419 
cyanid poisoning, 419 

bile in. 120 

bilirubin crystals in, 120 

blackish pigment in, 120 

character of, in membranes of brain, 
231 

Charcot-Leyden crystals in, 121 

coagulation of. at postmortem, 115 

color of, 113. 195 

cryoscopic index of, 114 

diabetic, reaction of, 224 

diseases of, viii, p. 113; 172, ^23, 427, 
432, 433. 434 

effect of air on, 1 19 

examination of, viii, p. 113: 228, 419. 
431, 438. 444 

freezing-point of, 114 

in drowning, 417 

gas-bubbles in, 121 

glycogen in, 120 

hxmatoidin crystal- in, 120 

in death by electricity, 413 



496 

Blood ni sunstroke, 414 
lesions of, 1 13 

macroscopic changes in, 113 
method of fixing, 338 

on body, location of, to be noted, 65 

organisms in, i_m 

pathologic conditions of, 115 

poisons in. [21 

removal of, for bacteriologic exami- 
nation, 444 

Specific gravity of, 1 14 

spectroscopic picture of, 418 

tests for, 118 

tumor-cells in, 120 

uric acid in. in gout, 128 
Blood-blisters, caused by costotome, 31 
Blood-color scale, postmortem, 113 
Blood-diseases, viii, p. 121 
Blood-flukes, 321 
Blood-plates, 122 
Blood-stains. 117 
Blood-tests, 113 

Blood-vessels, diseases of, 18, 20, viii, p. 
[34 ; 221, 224, 247, 307, 308, 314, 408, 
4-7 

examination of, 14, 441, 442, 443 

tumors of, 139, 140 
Blow-pipe, 32 
Board, Anatomical, 5 
Boards of Health, 4 

Boards to stand on while making post- 
mortem, 33 
Bodies, frozen, 289, 437 

intercarotid, 112, 260 

loose, in joint, 265 

rice, 261 
Body, see Cadaver. 
Bone, abscesses in, 268 

age of, how indicated, 58 

aneurisms of, 274 

angiomata of, 273 

ankylosis of, 71, 262, 263, 264, 267 

atrophy of, 264 

chondromata of, 273 

cysts of, 274 

decalcification of, 34.S 

deformities in dwarfism, 56 

diseases of, 70, 71, 72, 122, 123, 124, 
127, 246, xvii, p. 261 ; 303, 306, 308, 
317. 432, 461 
•n of, 268 

examination of, 14, 58, xvii, p. 261 ; 
439- 440 
in animals, 389 

fixatives for, 338 
: '-. 31 

fractures, 70 

haematoma of, 274 

inflammation of, 262 

injuries to, 267 

lipomata of, 273 

marrow of, 267 

measurements of, 57 



INDEX 



Bone, myxoma of, 274 

necrotic changes in, 267, 268 
osteomyelitis of, 270 
parasites of, 273 
rhachitic, 71 
sarcoma of, 274 
syphilis of, 264, 306, 307 
tuberculosis of, 264 
tumors of, 273 
Bony formations in muscle, 83 
Borders of organs, 16, 18 
Boric acid as preservative for food, 429 

toxicology of, 429 
Bothriocephalus latus, 121, 320 
Bovine tuberculosis, 373 
Bowel, see Intestine. 
Bow-leg, 71 
Box, refrigerator, 10 
Brachycephalic skull, 361 
Brain abscess, 246 

actinomycosis of, 255 

anaemia of, 247 

angioma of, 255 

anthrax of, 292 

cavity, injecting embalming fluid into, 

288 
charts of, 17 
child's, removal of, 276 
color of, method of preserving, 241 
congenital anomalies of, 249 
diameter of, 363 

diseases of, 14, 67, 68, 117, 132, 137, 
138, 149, 151, 233, xv, p. 246; 290, 
291, 299, 302, 307, 308, 313, 411, 432, 
.433 
dissection of, in animals, 388 
embolism of, 16 
encephalitis of, 250 
examination of, 14, 402, xii, p. 225 
Dejerine's method, 238 
Giacomini's method, 241 
Hamilton's method, 239 
Kaiserling's method, 343 
Meynert's method, 237 
Pitres's method, 237 
Virchow's method, 235 
fibro-endothelioma of, 255 
fibroma of, 255 
glioma of, 255 
gliosarcoma of, 255 
granulomata of, 255 
hardening of, 9, 241 

advantages of, 234 
with zinc chlorid, 241 
horizontal section of brain, 237, 240 
internal examination of, 234 
length of, 363 
lipoma of, 255 
measurements of, 363 
method of fixation, 338 
methods of sectioning, 234 
myxoma of, 255 
neurofibroma of, 255 



INDEX 



497 



Brain of animals, examination of, 388 

osteophytes of, 255 

parasites of, 255 

pathology of, xv, p. 246 

perithelioma of, 255 

psammosarcoma of, 255 

removal of, 7, 14, 52, 232, 276, 281, 439 
in animals, 387, 388, 394 
child, 276 

sarcoma of, 255 

sectioning of, 237 

specific gravity of, 363 

stem, weight of, 362 

syphilis of, 255, 307, 308 

table of weights of, 362 

time required for hardening, 338 

tuberculosis of, 311, 313 

tumors of, 255, 313 

vertical transverse incision of, 239 

volume of, 363 

weighing of, 232 

weight of, 360 
Bran, in preservation of body, 283 
Break-bone fever, 293 
Breast, abscess of, 61 

adult, 372 

atrophy of, 61 

cancer of, 61 

diseases of, 61, 81, 301, 317 

examination of, 61 

fluid in, 61 

hypertrophy of, 61 

infantile, 279 

infection of, 61 

lactation of, 372 

non-puerperal diseases of, 460 

pathologic conditions of, 81 

puerperal diseases of, 460 

shape of, 61 

size of, 61 

supernumerary, 61 

tumors of, 61 

weight of, at birth, 372 

wren's, 106 
Breathing, see Respiration. 
Bremer-Williamson reaction of diabetic 

blood, 224 
Bright's disease, complications of, 458 
skin eruptions in, 64 
synonyms of, 458 
Broad ligament, examination of, 14, 15 
Bromatotoxismus, 418 
Bromid, toxicology of, 421, 422 
Bromin, for disinfecting wounds, 34 
post-mortem wounds, 43 

toxicology of, 21, 422, 423 
Bromoform. 21 
Bronchial glands, diseases of, 145, 151. 

153, 155, 291, 301, 313, 3i6 
Bronchi, carcinoma of, 146 

diseases of, 116, 144, 145. 146. M7. I53i 
246, 291. 297, 316, 319. 408, 427, 
435 



Bronchi, examination of, 15, 441, 444 

fistula in, 144 

foreign bodies in, 146 

cedema of, 146 

primary tumors of, 146 

secondary tumors of, 146 

stenosis of, 146 

tumors of, 146 
Bronchiectasis, 144, 145, 150 
Bronchitis, 144 

acute, 144 

atrophic, 145 

capillary, 427 

catarrhal, 145 

synonyms of, 455 

cheesy, 146 

chronic, 144 

hypertrophic, 145 
synonyms of, 456 

complications of, 448 

croupous, 145 

death due to, 408 

due to gangrenous material in lungs, 
150 

fibrous, 145 

gangrenous, 146, 150 

hypertrophic, 145 

plastic, 145 

purulent, in typhoid fever, 319 

putrid, 144, 145 

subacute, 144 

suppurative, 145 

tuberculous, 145 
Bronchopneumonia, 151, 223 

complications of, 145, 294, 306, 448 

synonyms of, 456 
Bronchus, fluid in, examination of, 108 

left, position of, 108 

right, position of, 108 

stenosis of, 146 
Bronzed diabetes, 224, 422 
Bronzing of skin, 16 
Brooks, Phillips, 4 
Brown atrophy of heart, 129 
Bruises, location of, to be noted, 65 
Brunetti's chisels, 243 
Bubonic plague, 301, 373 
Bucket method of opening and cleansing 

intestines, 167 
Buffy angina, see Diphtheria. 
Buhl's disease, icterus neonatorum. 
Bulbs as a means of securing fluids for 

bacteriologic study, 347 
Bulk, determined by comparison, 18 
measurement, iH 
Virchow's method, [8 
Bullous emphysema of lungs, 150 
Burials, premature 
Burns. 412 

effects of, 412 

forms of, 463 

from corrosive substances, 463 
Bursae, 272 



498 

Bursitis. 273 

Butter yellow, toxicology of, 422 

Buttonhole mitral, 133 



Cachectic subjects, post-mortem rigidity 

of, 51 
Cachexia, changes of subpericardial fat in, 

101 
malarial, 322, 323 

pigmentation in, 112 
purpuric, 126 

Cadaver, bacteria in, 207 

breathing, absence of, 47 

closure of, after postmortem, 445 

color of skin of, 60 

contact with surrounding objects, 55, 
416 

cupping of, 47 

disembowelling of, 15, 276 

elevation of temperature of, 7 

embalming of, 286 

examination of exterior of, v, p. 46 

examination of, 437 

exterior of, examination of, v, p. 46 

frozen. 289 

identification of, 53 

lividity of, 49 

measurements of. 53, 56, 57, 358, 444 

pecuniary value of, 4 

place of finding, 55 

preservation of, xx, p. 286 
portions of, 5 

removal of, 54 

restoration of, xx, p. 283 

right to dispose of, by will, 4 

scarification of, 47 

subcutaneous injections into, 47 

surroundings of, 55, 416 

thawing of, 289 

weighing of, 10 

weight of, 59, 358, 360, 444 
•Caecum, diseases of, 308, 312 

examination of, 15, 166 

measurements of, 366 

removal of, 15, 165 
1 ill disease, 249 
reous deposits, 146, 272 

infarcts in kidneys, 200 

infiltration, 129 

of arteries, 135 
Calcicosis, 

Calcification in tuberculosis, 312 
Calcified bodies in abdominal cavity, 20 
Calculi, biliary, see Gall-stones. 

hydronephrotic, 200 

in pancreas, 196 

metamorphosed, 207 

renal. 206 

salivary, 260 
1, 206 



INDEX 



Calculous pyelitis, 203, 204 
Calipers, graduated, 32 
Calomel, toxicology of, 148, 424 
Calvarium, clamps for holding, 32 
diseases of, 230 
examination of, 229, 230, 439 
method of loosening, 227 
methods of removing, 226, 408 
in animals, 387, 391 
Campecia wood, effect on urine, 425 
Camphor, toxicology of, 421 
Canal of Wirsung, opening of, 188 

spinal, xiv, p. 242 
Cancer, see Carcinoma. 
Cancerous stomach, removal of, during 

life, 190 
Cannabinone, toxicology of, 421 
Cannabis indica, toxicology of, 421 
Cannula, 32 
Cantharidate, potassium, effect on urine, 

426 
Cantharides, toxicology of, 203 
Cantharidinate, potassium, effect on urine, 

424 
Cantharidine, toxicology of, 423, 424, 425, 

426 
Capsule of kidney, examination of, 178 
liver, 195 
organs, 16, 18 
Tenon, 257 
Caput medusae, 140 
Carbohydrate metabolism, 222 
Carbol-fuchsin for staining tubercle bacil- 
lus, 310 
Carbolic acid in treatment of post-mortem 
wounds, 43 
toxicology of, 411, 421, 422, 423, 
426 
Carbonates, alkaline, effect on urine, 424 
Carbon bisulphid, toxicology of, 421, 422 
dioxid, as a freezing agent, 12 
toxicology of, 48, 415, 421 
Carbonic acid, toxicology of, 421 
Carbon monoxid, toxicology of, 419, 421, 

425, 434 
Carbonyl chlorid, toxicology of, 422 
Carcinoma, 408, 451 

bodies, fixation of, 337 
colloid, of stomach, 190 
of bladder, 205 
breast, 451 
bronchi, 146 
choroid, 146 
ciliary body, 75 
clitoris, 69 
heart, 134 
intestines, 171 
kidney, 204 
larynx, 143 

liver, 190, 214, 215, 220 
lungs, 155 
lymph-vessels, 140 
mediastinum, 146 



INDEX 



499 



Carcinoma of nasal passages, 141 
navel, 66 
(esophagus, 190 

penis, 68 
pericardium, 99 
peritoneum, 1O0 
pleura. 156 
spleen, 1O4 
stomach. 190 
vulva, 69 
sarcomatodes of kidney, 204 
Cardiac plexus, dissection of, 270 
Cardol. toxicology of, 422 
Care of hands, iv, p. 38 

clothes removed from bod}-, 54 
Caries, 268 

of orbit. 76 
Carmin stains. 333 
Carnification of lung, 153 
Carnoy's fluids, as fixing fluids, 330 
Carotid arteries. 80, 112. 138. 232, 304, 442 
bodies, 112, 260 
tumors of, 112 
Cartilage, degenerations of. 264 

fixatives for. 338 
Caruncle of urethra, 70 
Cascarilla. to remove odor, 10 
Caseous nodules in tuberculosis. 316 
pneumonia, 311 
tuberculosis. 311 
Catarrh, acute nasal, 141 
atrophic. 141 
chronic nasal. 141 

adenoids in. 141 
fibrinous. 141 
hypertrophic, 
membranous, 141 
Catarrhal and croupous pneumonia, table 
showing difference between, 154 
appendicitis. 171, 172 
bronchitis. 145 
dysentery. 173 
laryngitis. 142 

pneumonia in typhoid fever, 318 
pyelitis. 203 
synovitis. 262 
Catheter., metal. 32 
Cat, postmortem of, 394 
Cau-es of death. 16. xxviii. p. 448 

complications of, xxviii. p. 448 
in 799 coroner's case 5 ;. 411 
nomenclature of. xxviii. p. 448 
synonyms of. xxviii, p. 448 
usual, xxviii. p. 448 
Caustic «alts. toxicology of, 423. 427 

soda for absorption of oxygen. 353 
Caustic^, effect of, on dead skin, 48 
toxicology of, 423 
used in treating post-mortem wounds. 

43 
Cautery, for post-mortem wounds. 43 
Cavity, abdominal. exooMire of. vi, p. 79 
of animals. 375 



Cavity, abdominal, exposure of, in dog, 
393 
topographic examination of, vi, 
P- 79 
cranial, of animals, 386 

of cow, after removal of bony 
vault, 390 
embalming, 288 
oral, of animals, 384 
thoracic, critical examination of, vii, 
P. 9-2 
exposure of, vii, p. 92 
of animals, 376 
Cells, ganglion, fixatives for, 339 
Cellular tissue, diseases of, 461 
Cellulitis, axillary, treatment of, 44 
of hand, treatment of, 45 
orbit, 258 
Central lesion of brain, no, 240, 302 

nervous system, actions of poisons on, 
419 
fixatives for, 338 
Centre governing development, 66 
Centrum ovale, methods of studying, 235, 

237 
Cephaeline, toxicology of, 423 
Cephalanthine, effect on urine, 425 
Cephalic cavities of a horse, lines for saw- 
ing, 387 
inspection of, xiii, p. 225 
method of opening, 387 
index, 360 

types distinguished by, 361 
Cephalonic skull, 361 
Cerebellum, average weight of, 362 
removal of. 236 
tuberculosis of 313 
Cerebral arteries, aneurism of, 247 
hemorrhage. 250 

as cause of death, 408 
hyperemia, 251 

softening, complications of, 453 
Cerebrospinal leptomeningitis, acute, 251 

meningitis, acute, 252 
Cerebrum, average weight of, 362 
Cervical organs in animals, dissection of, 

384 
ribs, 68 
Cervico-thoracic abdominal cavity, exami- 
nation of. 275 
Cervix uteri, malignant neoplasms of, 21 1 
Cestodes, 320 

intestinal. 320 
Chain hooks, 32 
saw, 259 

Chalky deposit- in gout. 127 
Chancre, 307 

of vulva, 69 
Chancroid. 351 

of vulva, 
Chantemasse, bacillus of. 172 
Charcot Leydeti crystals, i^r, 144 
Charcot's joint. 71, 248 



5oo 



INDEX 



Chart-, outline, how used, 17 
English gummed outline, 17 

Check, sucking gland in, 00 

Cheeks, fissures, 68 

Cheesy bronchitis, i4 (1 

Cheiragra, 263 

Cheiranthus, toxicology of, 424 

Chemic, inorganic poisons, 420 

organic poisons, 421 

poisoning. 10. 420. 42 1 
Chemicals detected by odors coming from 

body, 418 
Chenopodium, effect on urine, 425 
Chiara's raspatory, 31 
Chicken- tat clots, 115 
Chicken-pox, 351 
Child, full-term, healthy, dimensions of, 

359 
in postmortem, whether it is viable, 

403. 444 
preservation of body of, 275 
Chisels, 31 

guarded, 31 
hatchet-shaped, 31 
other kinds of, 31 
spinal, 31 
straight. 31 
T-shaped, 31 
Chloral hydrate, effect often difficult to 
determine, 429 
toxicology of, 421, 422, 425, 429 
Chlorate, potassium, toxicology of, 203, 

4-Vv 4-' 5 
Chlorin, toxicology of, 21, 422 
Chloroform and ether poisoning, deter- 
mined by odor, 430 
fright as an element in, 

429 
in evidence, but death 
due to other causes, 430 
toxicology of, 21, 411, 421, 
425, 429,. 430 
and its derivative-, toxicology of, 421 
narcosis, death from, 198 
Chlorosis, 122, 123, 452 

blood change- in, 122 
due to hypoplasia of aorta, 136 
Chlorphenol, odor of, 21 

toxicology of, 21 
Cholangeitis, suppurative, 219 
Cholccy-titi^. acute infectious, 215 
Cholelithiasis. 215, 220 
Cholera Asiatica, 292 

appearance of stools in, 293 

cneliac ganglion in, 293 

heart in, 293 

kidney in, 293 

liver in, 293 

lnngs in, 293 

mucous membrane in, 293 

odor in, 170 

mortem rigidity of abdomi- 
nal muscles in, 51 



Cholera morbus, 449 

nostras, synonyms of, 449 
Chondritis, 265 

Chondroma, due to misplaced cartilagi- 
nous tissues, 273 
of lungs, 155 

nasal passages, 141 
pleura, 156 
vulva, 69 
Chordae tendinese, 129 
Chorea, 249, 351, 453 
Choroiditis, syphilitic, 306 
Choroid plexus, 236, 439 
Christmas-tree, needles from, as evidence, 

55 
Chromates, toxicology of, 422, 423, 425 

Chromatolysis of cells of central nervous 

system in uraemia, 117 

Chromic acid as a fixing fluid, 330 

toxicology of, 423 

Chromo-acetic acid, as a fixing fluid, 331 

Chromo-aceto-osmic acid, as a fixing fluid,. 

Chromo-formic acid, as a fixing fluid, 331 

Chromo-nitric acid, as a fixing fluid, 331 

Chromo-osmic acid, as a fixing fluid, 331 

Chrysarobin, effect on urine, 422, 425 

Chrysoidin, toxicology of, 422 

Chyle duct, examination of, 197 

Chylothorax, 157 

Cicutoxin, toxicology of, 421 

Cimex lectularius, 319 

Cinchona bark, toxicology of, 422 

Circular method of removing calvarium, 

226 
Circulation, tests for, 47, 48 
Circulatory apparatus, diseases of, 454 
disturbances of kidney, 200 

lungs, 148 

system, syphilis of, 307, 308 

tuberculosis of, 314 

Cirrhosis, atrophic, of liver, 216 

Hanot's hypertrophic, 115 

of liver, 216, 224 

complications of, 458 
due to alcoholism, 427 
Cirsoid aneurism, 137 

of vein, 140 
Clamps for holding calvarium, 32 
Classification, Bertillon, of diseases, xxviii, 
p. 448 
of poisons, 420 
Clavicle and ribs, protection from injury 

from, 94 
Cleft scrotum, 69 

urethra, 69 
Clinocephalic skull, 361 
Clitoris, absence of, 69 
atrophy of, 69 
carcinoma of, 69 
hypertrophy of, 69 
Closure of body after postmortem, xa, 
p. 283 



INDEX 



Clothing, bullet-holes in, 54 
. care of, 54 
examination of. 54 
receipt for delivery of, 54 
stains on, 54 
Clots, chicken-fat. 115 
currant-jelly. 115 
fibrous, of aneurism, 138 
of pernicious anaemia distinguished 
from those of cancer, 122 
Clubbed fingers, 68, 269 

foot, 269 
Coal dust in hands, 16 
lungs, 16 
spleen. 163 
Cocaine, toxicology of, 421, 422. 425, 426. 

430 
Codeine, toxicology of. 422 
Code of Hammurabi, 1 
Cceliac ganglion, appearance of. in cholera 
Asiatica. 181, 293 
hemorrhage of. 293 
situation of, 181 
Coffee, burning of, to remove odor at 

postmortem. 10 
Colchicine, toxicology of, 421, 422, 423 
Cold, death from, 414 
Colitis, 174 

chronic, 175 
croupous, 153 
membranous, 174 
simple, 174 
ulcerative, 175 
Collection of material, 5, 326, 346 
Colloid cancer of lungs, 156 
stomach, 190 
material, formalin of Orth for fixing. 
340 
Coloboma, 75 

Colocynthine, toxicology of, 423 
Colon, dilatation of, 175 

diseases of. 153, 160. 172, 173, 174, 

175. 202. 312 
examination of, 15, 89, 165 
malignant disease of. 175 
measurements of, 366 
of animals, removal of, 379 
removal of, 15, 165 
tumors of. 171, 175 
Color changed by washing. 19 
of eyes, peculiarities of, 74 

racial peculiarities of. 74 
faeces, 170 
kidney after removal of capsule, 

178 
organs 16. 18. 109. 195 
values by kromskop. 18 
Colors, toxicology of anilin, 422, 426 
Colostrum, examination of, 81 
Coma, fatal. 21 
Comma bacillus of Koch, 292 
Common bile duct, see Ductus chole- 
dochus communi = . 



50I 

Comparative postmortems, xxv, p. 373 
Compensation in practice of medicine, 398 
Complications of causes of death, xxviii. 

p. 44S 
Compound fractures, 266 
Concentric atrophy of bone, 264 

hypertrophy of heart, 106. 133 
Conception, performing on cadaver opera- 
tion for prevention of, 3 
Concretions in kidneys, 200 
Condyloma of urethra, 70 
Cones, graduated, 33 
Congenital abnormalities of uterus, 209 
aneurism, 139 
anomalies. 17, 19, 249 
cystic kidneys, 200 
defects in kidney, 199 
deformities, 66 
dislocation of hip, 266 
diverticula of duodenum, 188 
luxation of sternum. 266 
redundancy of sigmoid flexure, 160 
rickets, 272 
syphilis, 307 

as cause of death, 408 
syphilitic pancreatitis, 221 
Congestion, hypostatic, 49, 149 
of kidney, 199 
liver, 218 
lungs, 149 
passive, of lungs, 148 
Coniine, toxicology of, 422 
Conium, toxicology of, 421 
Conjunctiva, 19, 74 

palpebral, hemorrhages of, 132 

in endocarditis, 132 
post-mortem changes in, 48 
Conjunctivitis, 74, 153 

gonorrhceal, 297 
Connective tissue, fixation of, 340 
Considerations, general, i. p. 1 
Consistency of organs, how affected and 

how determined, 17, 19. 195 
Constipation, 169 

Contagious diseases derived from domes- 
tic animals, 373 
Contents, abdominal, in animals, discission 
of, 383 
removal of. of a dog, 393 
in swine. 391 
of cavities. 20 

thoracic, removal of. in animals, 384 
Continued fever, see Typhoid fever. 
Contour of organs, 14. t8 
Contraction of bowels, [65 

pupiK a fter 'l<;ith. 48 
scrotum. 69 
Contracts between physician and patient, 

397 
Contractures, 71. 269 

of muscles, disappearance of post- 
mortem. 7T 
Contreroup, 230 



INDEX 



Convailaria, toxicology oi, 424 
Conviction of murder by poisoning, 420 
Com ulsions, 44 ,s - 453 
Copaiba, balsam of, toxicology of, 422 
Copper sulphate, purification of drinking 
water by, 430 

toxicology of, 423, 430 
Cord, diseases of, xv, p. 246 

examination oi, xiv, p. 242 

opening of, J44 

presen ation oi, 244 

removal of, 242. 277 

in animals. 389 
spinal, see also Spinal cord. 
syphilis of, 307, 308 
tuberculosis of, 313 
tumors of, 2^5 

weight and dimensions of, 364 

-. vocal, examination of, 11 1 

Cornea, appearance of, after death, 257 

post-mortem changes in, 48, 74 
Corneal abscess, 74 
Cornell head-rest, 225 
Cornutine, toxicology of, 421, 423 
Coronary arteries. 105, 129, 131, 135, 308 
obstruction of, cause of death, 408 
" pipe-stem" character of, 101 
Coroner, abolition of, 1 
authority of, 1, 5 
creation of, I 
duties 01'. 1 

office of, establishment of, 1 
Coroner'^ cases, 1, 411 

ilia, toxicology of, 424 
Corpora Arantii, 129 

epiadrigemina, 237, 439 

Cadaver. 
ulency, causes for, 50 
Corpus delicti, 55, 58, 401 
Corpus striatum, examination of, 439 
-ion. by poison, 426 
sive acids, toxicology of, 421, 423 
alkalies, effect on urine, 424 

toxicology of, 421 
metallic salts, toxicology of, 423 
poisons, toxicology of, 423, 425 
sublimate. 418 

for fixing tissues, 333 
Cortex of kidney, normal relation to me- 
dulla. 170 

ical lesion, 237 
Cor villosun 

nebacterium diphtheria?, 151, 350 
mallei. 291. 350 

Cory/a. 141 

"■ f '- 3^. 93 
Cotton, absorbent, in the preservation of 
the body, 283 
plugs. y?2 , y ? i 
■ 34 
and expert. 399 

testimony in. 17 



Court, weights and measures used in, 17 
Cover-slips, preparation of, 348 
Cow-pox, 351 

Cranial cavity, examination of, xiii, 439 
in animals, exenteration of, 386 
of cow, after removal of bony 
vault, 390 
dog, exposure of, 393 
horse, lines for opening, 387 
postmortem of, xiii, p. 225 ; 439 
Craniopagus, 67 
Cranioschisis, 249 
Craniotabes, 72 
Cranium, dimensions of, 363 

examination of, xiii, p. 225 ; 439 
sectioning of, in animals, 386 
vault of, substitute for, 284 
Crede's ointment, 44 
Creosote, toxicology of, 21, 411, 425 
Crepitation of lungs, how elicited, 109 
Cresol, toxicology of, 425 
Cretinism, 96, 249 

Cricoarytenoid joint, ankylosis of, 143 
Criminal abortion, 406 
Critical examination of organs of abdomi- 
nal cavity, x, p. 159 
thoracic cavity, vii, p. 92 
Croton oil, toxicology % of, 422, 423, 424 
Croup, 293, 448 

Croupous and catarrhal pneumonia, table 
showing differences between, 154 
bronchitis, 145 
colitis, 153 
gastritis, 153 

pneumonia, 151, 152, 154, 223 
gray hepatization in, 153 
hyperemia in, 152 
red hepatization in, 152, 153 
Crura of diaphragm, severing of, 236 
Crushing injuries to joints, 267 

suicide by, 463 
Cryer's electrical surgical engine, 30 
Cryoscopic index, 114 
Cryoscopy, 114, 416 
Crystalline lens, 75 
Crystals, Charcot-Leyden, 121 

hsematoidin, 120 
Csoker's method of removing thoracic and 

abdominal contents, in animals, 382 
Cubebene, toxicology of, 422 
Cultivation of organisms, 352 
Culture-media, inoculating, 351 
list of, 350, 351 
selection of, 349 
Cultures of anthrax. 356 

preparation of, for inoculation, 353 

from solid organs, 352 
smear, 352 
stab, 352 
stroke, 352 

used in inoculation, 353 
Cupping on dead subject, 47 
Curarine, toxicology of, 422, 425 



INDEX 



503 



Curcas oil, toxicology of, 422 
Currant-jelly clot, 115 
Curschmann's spirals, 144 
Curvatures of iliac arteries, 20 

spinal, 269 
Cutaneous diphtheria, 294 
eruptions in syphilis, 307 
form of tuberculosis, 318 
Cutting instruments, suicide by, 462 
Cyanid of cacodyl, toxicology of, 428 

potassium, toxicology of, 411, 419, 
430 
Cyanosis. 133. 216 
chronic. 128 

of skin in cholera Asiatica, 293 
Cyanotic cirrhosis of liver, 217 

induration. 133 
Cyclamine. toxicology of. 425 
Cyclocephalus. 67 
Cylindrical aneurism. 137 
Cystadenoma, papillary. 146 
Cvstic disease of kidney, 200 
duct, 1S8. 3$3 
formation in prostate. 212 
growths in nasal passages, 141 
kidney, incising of, 178 
Cysticercus cellulosse, 151, 320 
of bladder, 207 
bone, 274 
brain. 255 
heart, 134 
kidney. 202 
pericardium, 99 
Cystinuria, 424 
Cystitis. 205 

diphtheritic, 205 
due to alcohol. 427 

colon bacillus, 205 
effect on urine, 424 
Cy 5 ts, dermoid, in mediastinum, 146 
occlusion, 66 
of bones, 273 

Fallopian tube, 208 
iris, 75 
kidney, 200 
nasal passages, 141 
ovary, 209, 459 
pancreas, 196 
peritoneum, 159 
ureters, 204 
Cytisine, toxicology of, 421, 432 
Cytoglobin increased in haemophilia, 125 
Cytology, 417 
Cytolysins. 421 



Dactylitis syphilitic. 306 

Daylight, substitute for. at postmortem, 8 

Dead body, see Cadaver. 

Dead-house, arrangement of, 10 

library for. 12 

museum for, 12 



Death, ascertainment of cause of, 16 
by cold. 414 

drowning. 415 

electricity, 413 

hanging, 415 

heat. 414 

poisons, xxvi, p. 417 

starvation. ^14 

suffocation. 415 

throttling, 415 

traumatism with but slight exter- 
nal injury, 409 

violence, xxvi 
cause of, 16, xxviii. p. 448 
causes of, in 799 coroner's cases, 411 
circumstances of. 53, 437 
complications of causes of, xxviii, p. 

448 
cooling of body after, 49 
due to bolus of food in larynx. T43 

piece of lead-pencil in larynx, 

143 

ill-defined or unspecified * causes of, 

464 

in cases of abortion, usual causes of, 

407 
mask, 289 

microscopic changes in, 413 
molecular, 326 
nomenclature of causes of, xxviii, p. 

448 
of illegitimate child, concealment of, 

55 
pupils in, 46, 413 
rattle, 46 
signs of, 46 

cessation of all tissue vitality, 46 
complete loss of vital warmth. 48 
continuous cessation of circula- 
tion, 47 
respiration, 47 
earlier, 46 

inability to move, 46 
insensibility, 46 

loss of muscular irritability, 47 
nervous irritability. 47 
reflexes, 46 
negative, 46 
positive, 47 

putrefaction, most positive, 49 
varv under different condition-. 
46 
spermatozoa motile after, 46 
stiffening or poM-mortcm rigidity. 50 
Midden, flue to anaemic infarct of 
heart, 130 
aortic Stenosis, 133 

in infants from pressure on thy- 
mui 
synonyms of causes of, xxviii, p. 448 
three proximate causes of, 21 

time nft'-r. to make postmortem. 7. 
436 



504 



INDEX 



Death, usual causes of, 407, xxviii, p. 448 

violent. 403, 408 

Decapsulation of kidney, 3, 179 
1 )ecomposition, 50, 52 

delayed, 52 

discoloration oi, 52 

Eiofmann's treatment of, 52 
greenish color of, 50 
post-mortem, 52 

rapid. 52, 304, 414 
Deformities, 66, 71 
acquired, 66, 72 
asymmetrical, 66 
congenital, 66 

discovered by comparison, 71 
diseases associated with, 71, 72 
due to dislocations, 71 

embryologic defects, 66 

fractures, 71 

injury at birth, 66 

pathologic intra-uterine 
causes, 66 
' traumatism, 66 
laryngeal, 142 
multiple, 66 
muscular, 72 
orthopaedic, 268 
pathologic, 71 
single, 66 
symmetrical, 66 
Degenerated nerve-fibres, fixatives for, 

339 
Degeneration, 129 

albuminous, fixatives for, 338 
amyloid, 129, 135, 418 
fixatives for, 338 
of liver, 214 
cardiac, 129 
fatty, 129, 218, 223, 418 
of arteries, 135 
heart, 129 
liver, 218 
hyaline, 129 

of arteries, 136 
pancreas, 222 
lardaceous, 144 
myocardial, 129 
pancreatic, 196 
signs of, 70 
Dejerine's method of examining brain, 238 
Delirium, acute, 250 
Dementia, paralytic, 248 
Dengue. 293. 373 
Dental engines, 29 

tumor-, 7S 
Deodorants, 34 
Dermatomyo'-iti^. 63 
Dermoid cy-ts of lungs, 155 
mediastinum, 146 
orbit, 75 
ovary, 209 
uterus, 209 
Dermopathies, 248 



Determination of viability of child, 403, 

444 
Development, stunted, cause of, 70 
De Vilbiss's electrical surgical engine, 30 
Dextrocardia, 113 
Diabetes, bronzed, 224, 422 
complications of, 452 
insipidus, 127 

urinary changes in, 127 
islands of Langerhans in, 223, 224 
mellitus, 222, 223, 224, 452 
Diabetic blood, reaction of, 224 
Diacetic acid, 222 

Diagnosis, hypothetical or tentative, 16 
Diaphanous test, 47 
Diaphragm, cause of depression of, 85 
elevation of, 85 
diseases of, 148, 149, 197 
examination of, 13, 14, 15, 85, 197, 406, 
440, 444 
in animals, 376, 391 
height and location of, 17, 84, 85 
removal of, 275, 444 

in animals, 381 
Diaphragmatic pleurisy, 158 
Diarrhcea, summer, cause of, 172 
Diastasis, 266 
Dicephalus, 67 
Differentiation, optical, in preservation of 

tissues, 329 
Digestion, post-mortem, 87 
Digestive apparatus, diseases of, x, p. 150 : 

45.8 
Digitalis, toxicology of, 101, 421, 423, 424 
Dilatation of colon, 175 
heart, 133 
lymph-vessels, 140 
pupils after death, 48 
right heart, 144 
stomach, 190 
Dimensions, xxiv, p. 357 
how expressed, 17, 357 
of adrenals, 369 
babes, 358, 359 
bladder, 368 
children, 358 
cranium, 363 
embryos, 359 
gall-bladder, 367 
hair, 359 
heart, 364 
kidney, 368 
large intestine, 366 
liver, 367 
lungs, 366 
men, 358 
cesophagus, 366 
orifices of the heart, 365 
ovaries, 371 
pancreas, 369 
pituitary pdand, 363 
prostate, 372 
seminal vesicles, 372 



INDEX 



Dimensions of skull, 360 

small intestine, 366 
spinal cord, 304 
spleen. 369 
stomach, 366 
suprarenals, 369 
testes. 370 
thymus gland. 370 
thyroid gland, 370 
umbilical cord, 359 
ureters, 368 
urethra. 368 
uterus. 371 

vermiform appendix. 366 
vesicles, seminal, 372 
women, 358 
Dioxid. nitrogen, toxicology of, 422 
Diphtheria. 293, 448 
bacillus of, 151 
complications of, 448, 449 
corynebacterium of. Plate V, No. 6, 

P- 350 
cutaneous, 294 
endometritic. 210 
false membrane of, 294 
gastritic, 191 

growths associated with, 294 
laryngeal. 294 
mucous membranes in, 295 
nasal, 294 
of bladder, 206 

vulva, 69 
pharyngeal, 294 
pseudobacillus of, 293 
retropharyngeal abscess in, 294 
Diplococcus erysipelatis, 295 
pneumoniae, 151, 152 
varieties of. 349 
Diploe in animals, 390 
Diprosopus, 67 
Dipygus, 67 

parasiticus. 67 
Directors, grooved and curved, 32 
Discission means division of. 

of abdominal contents of animals, 383 
Discoloration, by poison, 426, 427 
Disease, Addison's, 16 
Barlow's, 126 
Basedow's, 97, 147 
Duke's, 300 

Glenard's, splanchnoptosis or abdomi- 
nal ptosis. 
Graves's. 97. 147 
Hodgkin's. 124 
von Jaksch's, 124 
of various organs and part- will be 

found indexed under their names. 
Q>ler'-. [28 
Paget's, of nipple. 324 
Raynaud'-. 254 
von Recklinghausen's 254 
Diseases, Bertillon classification of, xxviii. 
p. 448 



505 

Diseases, blood, 121 

contagious, and domestic animals, 373 
contracted at postmortems, 41 
diagnosed by agglutinative reaction, 

IJ 5 
due to haematozoa, xxi, p. 322 

micro-organisms, xxi, p. 290 
parasite;, xxi, p. 319 
specific organisms or proto- 
zoa not yet isolated, 351 
echinococcic, 322 
epidemic, 449 

following post-mortem wounds, 41 
general, 452 

hereditary, as cause of death, 408 
mortal, cause of sudden death, 407 
non-puerperal, of the breast, 460 
non-venereal, of the genital organs of 
the male, 459 
Disinfectants, 34 
Disinfection of hands after postmortem, 

40 
Dislocations, 20, 71, 263, 266, 286 
congenital, 71 

of hip, 66, 266 
of hyoid bone, 71 
neck, 66 

semilunar cartilages, 266 
pathologic, 71 
source of deformity, 71 
spontaneous, 71 
traumatic, 71 
Dissecting aneurism, 138 

wounds, 41 
Dissection of brain in animals, 388 
cardiac plexus, 276 
cervical organs, 384 
heart in animals, 385 
lungs in animals, 385 
oesophagus in animals, 384 
thoracic organs in animals, 384 
trachea in animals, 385 
Disseminated fat necrosis, 221, 222 

sclerosis, 254 
Distention of bowels, 165 
Distoma haematobium, 151, 202, 207, 220 
hepaticum, 159 
Westermanii, 151 
Distomiasis, 321 

Distribution of tubercles in body, 311 
Diverticula, of bladder, 206 

oesophagus, 190 
Dogs, postmortems on, 392 
Dolichocephalic skull. 301 
Dothienenteritis, see Typhoid fever, 
Double hearts, 113 
monsters, 67 
parasites, 67 
uterus, 209 
Dourine, 324 
Drains, n 

Drawing up of protocol of p<> tmortem, 
445 



33 



3 



o6 



INDEX 



•• Drill" bones, 83 

Dropsy, chronic articular, 262 

general, [56, 4(13 
Drowning, 415. 463 

appearance of skin after, 66 
freezing-point oi blood in, 417 

in salt and fresh water, difference of 
appearance in. 416 

suicide by, 462 

Duct-, liver, diseases of, xii, p. 213 
method oi examining, 188 
pancreatic, diseases of, xii, p. 220 

Ductus arteriosus (Botalli), 102, 276, 404 
choledochus communis, 15. 187, 188, 
104. 195, 196, 215, 216 

Duke's fourth disease, 300 

1 taodenal ulcer. 165 

Duodenum and its ducts. 187 

diseases o\, 196, 220. 221, 428 
examination of. 14. 15, 187, 442, 443, 

444. 
in animals, 383 
length of, 187, 266 
removal of, 15, 187, 443 
in animals, 379 
Dupuytren's contracture, 269 
Dura mater, adherent, loosening of, 227 
diseases of, 227, 230, 233, 244 
examination of, 230, 233, 439, 440 
French method of opening, 228 
hemorrhage in, 230. 233 
in animals, incising of, 387 
method of dividing, 231 
of spinal cord, 243 
removal of, 230, 440 

in animals, 387 
tumors in, 230 
Dura-tongs, 32 

Dusts, irritating, toxicology of, 422 
Duties of obducent during postmortem, 

437 
Dwarf, microsomic, 70 
Dwarfism, 56 
Dysentery, 172 
acute, 172 

catarrhal, 173 
amoebic, 173 
chronic, 172, 173 
complications in, 174 
'•pidemic. 449 
gangrenous. 173 
malignant diphtheritic, 173 
odor in, 170 
synonyms of, 449 



Ears, absence of helix, 68 

diseases of, 67, 70. 73. 128, 246, 252, 

253. 295. 301. 304. 306 
examination of, 14. 70. 233, xvi, p 

25X; 405. 439, 444 
hamatoma of, 16, 68 



Ears, middle, examination of, 158 

tumors of, 16 
Eccentric atrophy of bone, 264 

hypertrophy of heart, 106, 133 
Ecchymoses, 101, 171 
Echinococci, 322, S73 
of bladder, 207 
bone, 274 
brain, 255 
heart, 134 
kidney, 202 
liver, 220 
navel, 66 
pericardium, 99 
spleen, 164 
Eclampsia, 278, 279, 448, 453, 460 
Ectopia of testicles, 69 
Ectopic pregnancy, 207 
Ectromelus, 67 
Eczema of vulva, 69 
Elastic fibres, agents for fixing, 340 
tissue in arteriosclerosis, 134 
of spleen, 163 
Electric contractility in body after death, 
47 
disturbances, 463 
fan, 11 

light over post-mortem table, 11 
ose, 34 
Electricity, death by, 413 

appearance of blood in those 
dying from, 413 
heart in, 413 
pupils in, 413 
entrance of current in, 65 
indications of, 413 
microscopic changes in, 413 
Electrocution, 7, 413 
Electrolysis, aneurism treated by, 139 
Elephantiasis, 69 
Elongation of penis, 68 
Emaciation, 59, 414 

in atrophic cirrhosis, 57 

cancer of upper digestive tract, 59 
muscular atrophy, 59 
phthisis, 59 
Embalmed bodies, 286 
Embalming, arterial, 288 
cavity, 286 
fluid, 9 

effect of, on muscles, 82 
method of injecting into abdomen, 
286 
brain cavity, 287 
thorax, 287 
Nauwerck's, 287 
Emboli of carotid, 112 
Embolism, 112, 132, 137, 151, 246, 408, 455 
air, of lungs, 148 
fat, of lungs, 148 
of brain, 16, 246, 250 
pulmonary, 102, 148 
in chlorosis, 123 



INDEX 



5°7 



Embryos, fixation of, 2,2,7 

method of determining age of, from 
length of, 359 
Emetine, toxicology of. 423 
Emphysema, atrophic, of lungs, 150 

bullous, of lungs, 150 

local, complicating croupous bron- 
chitis, 145 

of liver, 218 

lungs, 149. 150, 151 

post-mortem, 95 

vesicular, of lungs. 150 
Empyema, frontal. 25S 

of antrum of Highmore, 141 
joint, 261 
pleura. 156 
Encephalitis. 250. 452 
Encephalocele, 68. 249 
Encephaloid cancer of lungs, 156 
Encephalon, maximum weight of, 361 

relative weight of. to body, 363 
Encysted pleurisy, 158 
Endarteritis, acute, 136 

chronic, 136 

obliterans, 135 

obstructive, 136 

proliferative. 136 
Endemic hepatitis. 219 
Endocardial vegetations of arch of aorta, 

100 
Endocarditis, 131 

benign, 132 

cause of hemorrhage into palpebral 
conjunctiva, 132 

complications of, 153, 210. 303, 304, 
448 

diphtheritic. 132 

fetal. 132 

fibrous. 132 

gonorrhceal. 297 

malignant, 16, 132 

metastatic inflammations associated 
with. 132 

mycotic. T32 

organisms of, 132 

rheumatic, 132 

septic. 132 

syphilitic, 132 

ulcerative. 132 

ulcerosa in erysipelas, 295 

varicose. 132 

vegetative. 132 
Endocardium, diseases of, 131, 132 
Endocyma. 68 
Endometritis, acute, 209 

as a cause of spontaneous abortion. 
407 

atrophic, 210 

chronic hypertrophic, 210 

diphtheritic. 210 

gangrenous. 210 

hemorrhagic. 210 

tuberculous 210 



Endophlebitis, fibrous. 140 
Endothelioma of lungs. 156 
peritoneum. 159 
pleura. 156 
Engines, dental and trephining, 29 
Enlargement, see Hypertrophy. 
Enophthalmus, 258 
Enostosis of bone, 273 
Ensiform appendix, hook-shaped, 94 
Enteric fever, see Typhoid fever. 
Enteritis and diarrhoea, synonyms of, 457 

as cause of death, 408 

nodularis in diphtheria, 295 
Enterorrhagia, 128 
Enterotome, 31 
Enzymes, toxicology of. 421 
Eosin and methylene blue, 341 
Eosinophilia, 116 
Ephedrine, toxicology of. 422 
Epidemic affections, 449 

cerebrospinal meningitis, synonyms of, 
452 

erythema, 351 
Epiglottis, 15, 73, 96, no, 142, 256 
Epilepsy. 453 
Epiphyseal fractures, 127 
Epispadias, 68 
Epistaxis, 128, 142 
Epithelial nephritis, 199 
Epithelioma of larynx, 143 
lungs, 156 
nasal passages, 141 
tonsils, 143 
Epithelium, oesophageal. 189 
Epulis, 78 

Equipment for bacteriologic investiga- 
tions, 346 
Equivalents of kilogramme and litre, 357 
Erectile tumor of arteries. 137 
Erection of penis, post-mortem, 68 
Ergotism, 418. 421, 423 424, 430 
Erlicki's solution for fixation of ti--ues, 

333 
Erosion of bone, 268 
Erosions of vagina. 211 
Eruption, cutaneou-. in syphilis, 307 

herpetic. 141 
Erysipelas, 295 

ambulans. 295 

of larynx. 142 

phlegmonous. 295 

simplex. 295 

synonym^ of. 449 
Erythema, epidemic, 35' 
Erythromelalgia, 250 
Essential anaemias, 1x6 
Ether, as a freezing agent, 12 

toxicology of. 21. 421. 429. 430 

Ethereal oil of mustard, toxicology of. 422 

oil-, odor 

toxicology of. 422. 425 
Ethyl chlorid, 12 
Eustrongylua gig.< 



508 



INDEX 



V.\ ersion of eyelids, 73 

Evidences of development of infant, 405, 

406 
Evisceration of new-born, 275 
Exalgin, toxicology of, 423 
Examination, critical, of abdominal cav- 
ity, x, p. 159 
thoracic cavity, vii, p. 92 
external, 52, 438 

of lower animals, scheme for re- 
cording, 394 
in cases of criminal abortion, 406 
internal, in postmortem, 439 

of lower animals, scheme for re- 
cording, 394 
microscopic, in postmortem, 438 
of adrenals, 14, 179 
aorta, 14, 197, 441 
of animals, 383 
appendix, 15, 166, 171, 443 
base of skull, 233 
bladder, 14, 15, 181, 442 
blood, viii, p. 113 ; 444 
bones, xvii, p. 261 

of face, 281 
bowel in animals, 383 
brain, xiii, p. 225 

in animals, 389 
capsule of kidney, 178 
child, 275 
chyle-duct, 197 
contents of stomach, 189 
cord, xiv, p. 242 
diaphragm, 14, 15, 197 
dura mater, 230 
ears, 14, xvi, p. 258 
exocranial sinus, 260 
exterior of body, v, p. 46 
external surface of brain, 233 
eyes, 14, xvi, p. 256 
female genital tract, 207 
gall-bladder, 14, 15, 100, 194, 441 
inner table of skull, 230 
intestines except the duodenum, 

164 
joints, xvii, p. 261 
kidney, 14, 178 
liver, 103, 195 
lungs, 14, 15, 97, 109, 441 
macroscopic specimens, 341 
male genital tract, 21 t 
mastoid process, 260 
mesenteries, 159 
middle ear, 258 
nasopharynx, xvi, p. 256 
oesophagus, 14, 15, 189 
omentum, 150 
oral cavity, 281 
ovary, 14, 15, 183, 442 
pancreas, 14, 15, 196, 442 
pericardium, 13, 14, 15, 198, 441 

in animals, 384 
peritoneum, 14, 15, 159 



Examination of prostate, 212 
retina, 257 

retroperitoneal lymph-glands, 196 
salivary glands, 260 
scalp, 225 
skull, xiii, p. 225 
spermatic cord, 212 
spinal canal, 242 

cord, xiv, p. 242 
spleen, 14, 15, 163 
stomach, 14, 15, 188, 443 

in animals, 383 
thoracic duct, 14, 15, 197 
uterus, 14, 15, 184, 209 
vagina, 15, 210 
vena cava, 197 
order of, at postmortem, ii, p, 13 
post-mortem, of inoculated animals, 
355 
birds, 394 
lower animals, 374 
new-born, xviii, p. 275 
restricted, xix, p. 280 
topographic, of parts contained in 
abdominal cavity, vi, p. 79 
Examinations, bacteriologic, 14, xxiii, p. 
346 
medicolegal, post-mortem form of 
report in, 403, 447 
Examiners, medical, 1 
Exanthematous typhus, synonyms of, 448 
Excision of liver of animals, 379 
Excitomotor alkaloidal poisons, 421 
Excrescences, calcareous, of trachea, 146 

papillomatous, of trachea, 146 
Exencephalus, 67 

Exenteration in dorsal position, 381 
of animals, Vienna method of, 382 
cranial cavity in animals, 386 
liver in animals, 381 
pancreas in animals, 381 
pelvis in animals, 385 
spleen in animals, 381, 382 
stomach, 381 
Exfoliation of cartilages of larynx, 143 
Exophthalmic goitre, 147, 452 

presence of thymus gland in, 95 
Exophthalmus, causes of, 258 
Exostosis, 273 
Expert and court, 399 

medical man as an, in medicolegal 

cases, 400 
testimony, 398, 399, 401 

sure ground to be adhered to, 401 
unsafe ground to be acknowl- 
edged, 401 
Exploratory puncture, fatal, 65 
Exposure of abdominal cavity of animal, 
375 
accessory sinuses in animals, 389 
thoracic cavity of animals, 376 
technic of, vii, p. 92 
Exterior of body, examination of, v, p. 46 



INDEX 



509 



External anthrax. 291 

developmental period of infant, 405 
examination of body, v, p. 46 : 438 

lower animals, scheme for re- 
cording, 394 
method of examining testicles. 186 
Extract of male fern, toxicology of, 422 
Extrameningeal hemorrhage, 251 
Extra-uterine pregnancy, 207 
Extremities, deformity of, in rhachitis, 71 

of an animal, removal of. 375 
Exudates. 20. 86 

acute inflammatory, fixative for, 338 
chylous, 86 

distinguished from transudate, 86 
encapsulated peritonitic, at navel. 66 
fatty. 86 

how distinguished, 86 
odor of suppurative, 86 
varieties of, 86 
Eyelids, diseases of, 73, 128, 291, 295, 416 
movements of, when head has been 

severed. 47 
puffiness of, 73 

in arsenical poisoning, 73 
Bright's disease, 73 
cardiac affections, 73 
traumatism, 73 
Eyes, 73, 257 

abnormalities of, 73 
- appearance of, in apoplexy, 48 

carbonic acid poisoning. 48 
hvdrocyanic acid poisoning, 
'48 
artificial. 73 
color of, 74 

conjugate deviation of, in apoplexy, 74 
conjunctiva of, 74. 297 
consistency of, 258 
cornea of, 74 

crystalline lens of, coloboma of, 75 
diseases of, 67, 73, 74, 75, 7&, 253, 257, 

295. 297, 301. 306, 308, 432 
examination of, 14, 47, 48, 73, 75, xvi, 

p. 257: 438, 444 
expression of, at death, 73 
gonorrhoeal infection of, 297 
growths in. 75 

macroscopic examination of. 257 
measurements of, 74 
microscopic examination of. 2-7 
optic nerve of, 75 
orbital injuries of. 76 
position of. 73. 258 
post-mortem changes in, 48 
protru-ion of. 258 
pupils of, 74 
removal of, 257. 282 
retraction of. 258 
sarcoma of. 16 
sclera of. 75 
^yphili- of. 306 
tumor- of. \C). 74 



F 



Face, appearance of, after death, 47 
examination of, 260, 439 
in death by electricity, 413 
Facial angle of Camper, 361 
Facies hypocratica, 47 
Faeces, color of, 170 

in partakers of opium, 169 
Fallopian tubes, 207 

anomalies of, 207 
cysts of, 208 

diseases of, 207, 208, 297, 315 
examinations of, 14,. 15, 185, 442 
hematosalpinx, 208 
hemorrhages of, 208 
hydrosalpinx of, 208 
pregnancy in. 207 
pyosalpinx of, 208 
removal of, 183, 184 
tumors of, 208 
False aneurism, 137 
joint, 266 

membrane of diphtheria, 294 
sand in intestines, 170 
Falx, detachment of, 231, 277 
Fan, electric, 11 
Farcy, 296, 449 
Fat, color of, 80 

embolism of lungs, 148 

necrosis, 196, 221, 222 

Fatty changes in liver, 218 

methods of fixing, 340 
cirrhosis of liver, 217 
degeneration, 129, 223, 418 
of arteries, 135 
liver, 218 
marrow, 267 
infiltration, 129 

of liver, 18, 219 
pancreas, 221 
Favus, 192 
Fecal fistulas, 457 
Feet, diseases of. 296, 299, 438 
Felon, 268 

Female genital tract, 207 
Femoral hernia, contents of, 20, 73 
Fever, break-bone. 293 
cerebrospinal, 252 
dengue, 293 

exanthematous, synonyms of. 448 
glandular, 295 
hay, 142 

intermittent, synonyms of, 448 
malarial. 322 

mosquitoes in, 322 
malta. 300 
Mediterranean, 300 

miliary. 351, 410 
paratyphoid, 169 
recurrent, synonyms <>f, 44S 
relapsing, 302 
rheumatic, 303 



INDEX 



Fever, scarlet, 303, 351 

distinguished from Duke's fourth 
disease, 300 
trypanosoma, 324 
typhoid, 318, 408, 44S 
typhus, 62, 351, 448 
yellow, 319, 351, 373, 44') 
mosquito in, 319 
Fevers, infectious, as cause of death, 408 

abortion from, 407 
Fibrin, agents for fixing, 340 
Fibre endothelioma, of brain, 255 
Fibroid changes in lung, 153 
myocarditis, [33 
phthisis, 311, 315, 316 
Fibroma in nasal passages, 141 
of bladder, 205 
brain, 255 
heart. 134 
intestines. 171 
kidney, 204 
liver, 220 
lungs, 155 
ovaries, 209 
peritoneum, 159 
pleura, 156 
tonsils. 143 
urethra, 70 
uterus, 209 
vulva, 69 
Fibromyxoma in nasal passages, 141 
Fibrosis of aortic valves, 129 
Fibrous bronchitis, 145 
clot of aneurism, 138 
endophlebitis in veins, 140 
heart. 129 
nephritis, 199 
polyps of heart, 134 
tumors in nasal passages, 141 
Filaria sanguinis hominis, 159, 202, 207, 

321 
Filicic acid, toxicology of, 421 
Fimbricated hymen, 69 
Final report of postmortem, 445 
Fingers, absence of, 68 
atrophied, 68 
clubbed, 68 
bypertrophied, 68 
Mipernumerary, 68 
webbed, 68 
Finger-stalls, rubber, 40 

irms, suicide by. 462 
Fish-bone in omentum, 20 
Fish poisoning, toxicology of. 422, 423 
•' anus. 69 
cheeks, 68 
penis 68 
sternum, 68 
Fistula in ano, 3 '3 
Fistula of bronchi, 144 

rectum following abscesses, 69 
trachea. 144 
Fixatives, 7,27. 72%, ^4^ 



Fixatives, pathologic conditions suggest- 
ing certain, 338 
penetration as a characteristic of, 329 
Fixing fluids, 329 

smear preparations, 348 
Flaxseed poultices for post-mortem 

wounds, 44 
Flax thread, coarse, 38 
Flea, common, 319 
Flemming's fixative, 2> 2 7 

solution, 336 
Florida, phthisis, 311, 315 
Fluid, embalming, 9 

in peritoneal cavity, color of, 85 

normal amount of, 85 
pleural cavity, amount of, 97 
character of, 97 
peritoneal, collection of, from inocu- 
lated animals, 356 
Fluids, fixing, 329, 348 

preserving, 342 
Fluorescence, as a pathologic force, 404 
Fluorescin, 47 
Fly, Spanish, toxicology of, 422 

tsetse, 324 
Fcetal atelectasis of lungs, 147 
Foetus, absence of post-mortem rigidity 
in, 52 
immature, 52 

percentage of water in, 360 
post-mortem expulsion of, 46, 51 
Follicular appendicitis, 171 

conjunctivitis, 454 
Fontanels, examination of, 444 
Foot-and-mouth disease, 295, 351 
Foot, perforating ulcer of, 248 
Foramen of Monro, opening of, 236 
Forceps, 31, 32 
curved, 31 
dissecting, 31 
other forms of, 32 
pointed, 31 
straight, 31 
Foreign bodies in abdominal cavity, 88 
air-passages, 146 
heart, 134 
joints, 267 
pericardial cavity, 99 
uterus, 210 
Form of physician's certificate for return 
of a death in America, 464 
report in medicolegal post-mortem 
examinations, 403 
Formad pocket-case, 36 
Formalin (formaldehyde), for embalm- 
ing, 9 
for fixing retina, 339 
tissues, 335 
hardening brain, 9, 241 
preserving fluid, 342 
in preservation of macroscopic speci- 
mens, 342 
toxicology of, 21, 421, 430 



INDEX 



5TI 



Formates and formic acid, toxicology of, 

Formic acid, toxicology of. 425 
Fourth disease. Duke's, 300 
Fractures. 20, 70, 266 

by contrecoup, 230 

compound, 266 

epiphyseal, 127 

forms of, 17, 20, 463 

of hyoid bone. 71 

laryngeal cartilages, 71 
neck, 66 
orbit, 76 

overlooked. 71 

recent, usual signs of. 71 
Fraenum of tongue, deformities of, 68 
Fragilitas ossium, 265 
Fragmentation of heart, 129 
Frambcesia. 296 
Freezing, 463 

agents, 12 

of bodies to preserve, 289 

point of blood, 114 

in drowning, 417 
French method of opening dura, 228 

skull, 228 
Fresh material for microscopic observa- 
tion. 347 
Freud's gold stain, t,^, 341 
Friedreich's ataxia, 248 
Fright, death from. 198 
Frozen bodies, 289, 414, 437 

sections, 12 
Fuchsin. toxicology of, 425 
Fungi-joint in adiposis dolorosa, 59 
Fungi, poisonous, toxicology of. 424 
Funnel-heart of rhachitis, 72 
Furuncle, 461 
Fusiform aneurism, 137 



Gabbett's solution for staining tubercle 

bacillus, 310 
Galactotoxismus. 418 
Gall-bladder. 193 

absence of, 215 

bacteriologic examination of, 194 

dimensions of, 367 

diseases of. 195, xii, p. 215; 220 

examination of, 14, 90, 193, 194 

impaction of, due to gall-stones, 
216 

measurements of, 367 

removal of, 193 

tumor'; of. 42, 195 

weight of. 367 
Gall-duct-. xii. p. 215 

Gall-stones 170. 195, 215 

composition of. 216 

number of. 216 

shape of. 216 



Ganglia, semilunar, 181 
spinal. 243 
study of, 181 
Ganglion, 273 

cells, fixatives for, 339 
Gasserian, 282 
Gangrene of bladder, 205 
hand, 45 

lungs, 150, 153, 456 
circumscribed, 150 
diffuse, 150 
penis, 68 
Gangrenous appendicitis, 172 
bronchitis, 146 
dysentery. 173 
endometritis, 210 
ergotism, toxicology in, 423 
lymphangitis of scrotum, 69 
pancreatitis, 220 
Gas bacterium, 349 

bubbles in blood, 121 
fixtures over post-mortem table, 11 
in abdominal cavity. 84 
odor of, in perforation of stomach, 84 
Gases, deleterious, absorption of, 463 

irrespirable, 420, 421 
Gasserian ganglion, 282 
Gastrectasis, 190 
Gastric cancer, 189, 190 

contents, reaction of, 189, 418 
ulcer, situation of, 189 
walls, atony of. 191 
Gastritis, 191 
acute. 191 
atrophic, 192 
chronic, 191, 192 
croupous. 153 
diphtheritic, 191 
due to alcoholism. 427 
hypertrophic, 192 
mycotic, 192 
phlegmonous, 191 
simple, 191 
suppurative. 191 
toxic, 192 
Gastro-intestinal form of influenza, 299 
tract in alcoholism. 427 
syphilis of. 308 
Gastroptosis. 61 
Gastrorrhapia. 128 
Gelatin of Wharton. 276 
Gelsemine, toxicology of. 421. 422 
General considerations, i. p. 1 : 439, 440 

in preservation of tissues, 342 
Genitalia, female. if, 56, 69, 207, 

405, 438. 444. 4fa> 
removal of. [83 
in acromegaly, 56 

male of, 56. 68, 211, 405. 438. 

444. 459 
removal of, 185. 442 
Genito-urinary system, '!i <n^es of, xi. p 
\<s>: 314. 427 



5>- 



INDEX 



Genito urinary system in alcoholism, 427 

tuberculosis of, 3'4 
Genu extrorsum, 71 
valgum, 71. 268 

varum. 71 

German measles, 303 

how distinguished from Duke's 
fourth disease, 300 
Gersung's method. 3 

Gestation, period ^i intra-uterine, how de- 
termined from examination of foetus, 

4°S 
Giacomini's method of hardening brain, 

241 

Giantism, 56, 70 

Gilson's solution for fixation of tissue, 334 
Glacial acetic acid, for post-mortem 

wounds, 43 
Glanders, 296, 373, 449 
Gland, pineal, see Pineal gland, 
pituitary, see Pituitary body. 
thymus, see Thymus gland. 
thyroid, see Thyroid gland. 
Glands, alcohol as a fixative for, 340 
Bartholinian, enlargement of, 69 
cervical, enlargement of, 295, 297, 301 
diseases causing enlargement of, 66 
lymphatic, tuberculosis of, 66, 316 
mammary, diseases of, 61, 81 
examination of, 81 
tuberculosis of, 317 
maxillary, weight of, 366 
mesenteric lymphatic, hyperplasia of, 

in typhoid fever, 318 
peribronchial, caseating, 134 
retroperitoneal lymph, examination of, 

196 
salivary, 260 
tuberculous, 16 
Glandular fever, 295 
Glass balls, 32 

cones, graduated, 32 
graduated measuring vessels, 32 
ssels for preserving specimens, 34, 
444 
Glaucoma, 258 
Glioma of brain, 255 

retina. 75 
( ilio-arcoma of brain, 255 
Glisson's capsule, 224 

»ary index. 22. xxx. p. 489 
Glossina palpalis, 324 
Glottis, oedema of, 426 
. rubber. 34, 343 
Glycogenic reaction of blood. 120 

Glycosuria, 222 
Gmelin's tesl for bile, 120 
Goat, acute meningitis of, 2^3 
Goitre. 146, 249 

colloid, 96 

congenital, 96 
. 1 46 

exophthalmic, 147, 452 



Gold stains, 341 

Golgi chrome-silver preparation, 341 

Golgi's stains, 332, 341 

Gonococcus, 350 

Gonorrhceal affections of child, 450 

arthritis, 263, 297 

hydrocele, 417 

infection, 297 
" Goose-flesh," appearance of skin in 

drowning, 66 
Gout, 127, 452 

chalky deposits in, 127 

chronic, 262 
Gouty arthritis, pathology of, 263 

urates in chronic tenosynovitis, 272 
Graduated cones, 33 
Grains, 357 
Grammes, 357 

when used, 17 
Granular kidneys, 179 
Granulation tissue, methods of fixing, 340 
Granulomata of brain, 255 

iris, 75 
Graves's disease, see Basedow's disease. 
Gray hair, cause of, 76 
Grippe, 298, 449 

complications of, 299 

synonyms of, 449 
Guaiacol, effect on urine, 425 
Guinea-pigs, how affected by X-rays, 261 

inoculation of, 45, xxiii, p. 346 
Gumma, 69, 99, 233, 306, 307, 308, 309 
Gummata of pericardium, 99 
Gunshot wounds, in violent death, 408 
Gyrinus natator, toxicology of, 426 



Haematemesis, 128 
Haematocele, 69 

vaginal, 211 
Haematochromatosis, 224 
Haematoidin crystals, 120, 201 
Hematoma of bones, 274 
ears, 16, 68 
vulva, 69 
Haematomyelia, 250 
Hematoxylin, effect on urine, 425 
Haematozoa, xxi, p. 322 
Haemoglobin, diffusion of, into tissue, 50 

percentage of, in blood twenty-four 
hours after death, 113 
Haemolysins, 421 

Haemolysis, diseases present in, 116 
Haemopericardium, 98, 99 
Haemophilia, 125, 129 
Haemoptysis, 128, 148 

parasitic, 321 
Haemothorax, 157 
Hair balls, 189 

color of, 76 

diseases of, yy 

distribution of, yy 



INDEX 



5 l 3> 



Hair, examination of, 76. 430. 438, 444 

growth of, after death, 46 

injuries and tumors under. 20, 77 

length of, 76 

loss of, 77 

quality of, 77 

quantity oi, 77. 306. 307 
Hallux valgus. 269 
Hamilton's method of examining brain. 

239 
Hammers. 31 

Hand-bag for carrying instruments. 34 
Hands, amputation of, in spreading gan- 
grene. 45 

care of, and treatment of post-mortem 
wounds of. iv, p. 38 

cellulitis of. how treated. 45 

diseases of, 45. 59. 68. 246, 250, 254, 
299 : 303. 304. 307 

examination of. 47. 68 

palms of, color of. in corpse. 47 

post-mortem position of. 51 

tumors of. 44. 272, 
Hanging. 112. 415. 462 

and throttling, differentiation of. 415 
Hanot's hypertrophic cirrhosis. 115 
Hardening of tissues, t,t,7 

brain, advantages of. 234 
Harelip, 68 

Harke's method for examining nasophar- 
ynx. 256 
Hay fever. 142 
Head, diseases of, 67 

examination of. 14. 22?. 438. 439. 444 

measurements of, 56. 444 

of animals, removal of. 386 

rests, it 

size and shape of. 22^ 
Health, Boards of. 4 
Heart, abnormalities of. 113 

abscess, metastatic, of, 130 

actinomycosis of, 134 

adiposity of. ior. 106 

amyloid degeneration of. 129 

anaemic infarct of. cause of sudden 
death. 130 

aneurism of, 130 

anomalies of. 113 

appearance of. in cholera A viatica, 
293 

atrophy of. 106 

beat, absence of, on palpation and 
auscultation. 47 

brown. 106 

carcinoma of. 134 

characteristics of. vii. p. 100: viii. p. 

TI3 
color of. 100. 106 
complication-. 4" 
concentric hypertrophy of. 133 

conM-tenre of. too. 106 

'icerci of, 134 
degeneration- of. 120, 



Heart, dilatation of, 106, 133 
dimensions of, 364 

diseases of, viii, p. 113; 135, 138, 144, 

147. 200. 272, 290, 291, 292, 203. 294, 

299, 302, 303, 304, 305, 311, 316, 318, 

323. 408. 411. 419, 427, 431, 433. 441 

displacement of, how determined, 100 

double, 113 

eccentric hypertrophy of, 133 
ecchymoses of, subpericardial, 101 
echinococci of, 134 
enlargement of, causes of, 100 
examination of, 14, 15, 100, 101, 441. 
445 
in animals, 385 
exhaustion of, as cause of death, 408 
fatty degeneration of, 106 
fibromata of, 134 
fibrous, 129 

polyps of, 134 
foreign bodies in, 134 
fragmentation of, 129 
hypertrophy of, 106, 133 

in tuberculosis, 316 
in animals, dissection of, 385 

death by electricity, 413 
infarcts of, 130 
infiltrations of, 129 
injuries to, 99, 129 
in overdoses of digitalis group, 419 
lesions, as a cause of death, 408 

valvular, 303 
lipomata of, 101, 134 
lymphosarcomatosis of, 134 
measurements of. too. 364 
measuring and testing valves of, 103 
melanotic sarcoma of, 134 
method of opening, 101 
miliary tubercles of, 134 
muscle, in diphtheria, 106 
typhoid, 106 

soft in sepsis, 106 

suturing of, 100 
myomalacia of, 130 
myxomata of, 134 
organic diseases of. 454 
pentastomata of. 134 
primary incisions of. 102 
removal of. from body. 15, 05, 102, 
280, 441 
in animals. ^2 
rhabdomyomata of. 134 
Htfht. dilatation of, 144 
rudimentary. 113 
-arcoinata of. 134 
sclerosis of. [31 
secondary incisions of. 104 
segmentation of. 
simple hypertrophy of. 133 
aneous rupture of. T29 
syphilis of. 13^. 307. 308 
thrombosis of. 137 
traumatism of. 99, 129 



5 l 4 



INDEX 



Heart, tuberculosis of, [34, 31 1 
tumors of, 99, ioi, [33, 134 
valvular diseases of, [33, -'oo 
volume of, 365 
weight of, [OS, 100, 360 

proportion, to body weight, 364 
Heat, death from. 414 

decomposition in death from, 414 
in smear preparations, 348 
1 [ea1 stroke, 414 

post mortem rigidity after, 51 
Heberden's nodosities, 263 
Heidenhain-Biondi triple stain, 333, 341 
Height, 56 

average (European standard), 358 
methods of determining, 56 

approximate, 56, 57 
Helix of ears, absence of, 68 
Hellebore, toxicology of, 424 
Helvellac acid, toxicology of, 423, 425 
Hemiplegia. 250 

Hemispheres of brain, examining, 239 
Hemorrhage as a complication of scar- 
latina. 444 
causes of, 128 
cerebral. 2=;o 

as cause of death, 408 
complementary, 128 

synonyms of, 453 
complications of, 453 
consecutive, 128 

due to acute yellow atrophy of liver, 
95 ' 
phosphorous poisoning, 95 
trauma, 95, 128 
vicarious menstruations, 128 
extrameningeal, 128, 251 
fatal. 49 

from cord, as cause of death, 128 
laceration of liver, 20 
stomach, 192 

wounds, as a therapeutic measure, 
43 
intestinal, tjt, 448 
into air-cells and lung tissue, 148 
dura. 230. 233 
mediastinum, 95 
mesentery, 160 
pancreas, 196 
spinal membranes. 251 
sympathetic nerves. T12 
meningeal, 251 
nasal, 128 
non-puerperal uterine, svnonvms of, 

4.S9 
of bowel. 171 

Fallopian tube-. 208 
liver, fatal, 65 
lungs. 148 
pancreas, 220 
spinal membranes. 251 
umbilical cord, [28 
uterus, 209 



Hemorrhage per diapedesis, 128 
rhexin, 128 

petechial, 145 

puerperal, synonyms of, 460 

pulmonary, 128 

after calomel injections for syph- 
ilis, 148 

renal, 203 

secondary, 128 

subcutaneous, in plague, 302 

synonyms of, 455 

varieties of, 128 
Hemorrhagic, chronic, peritonitis, 161 

endometritis, 210 

exudate, 86 

infarct, 136 

in mesentery, 160 

scurvy, 127 
sinks in water, no 

pachymeningitis, 162 

pancreatitis, 220 

pleurisy, 157 

pyelitis, 203 

smallpox, 305 
Hemorrhoids, internal or external, 69, 140 
Henoch's purpura, 126 
Hepatic duct, examination of, 194 

peritoneum, mechanical irritation of, 3 
Hepatitis, endemic, 219 

pysemic, 219 

suppurative, 219 

tropical, 219 
Hepatization, red and pray, in croupous 

pneumonia, 152, 153 
Hereditary ataxia, 248 

syphilis, 306 
Hermann's fixative, 327 
Hermaphrodite, 55 

sex of, 55 
Hernia, 73 

complications of, 457 

examination for, 90 

femoral, containing appendix, 20 

frequent varieties of, 90 

infrequent varieties of, 90 

inguinal, containing sigmoid flexure, 
20 

of scrotum, 69 

usual locations of, 73 

vaginal, 211 
Hernial aneurism, 137 

opening of omentum, 159 
Herpes progenitalis, 69 
Herpetic eruptions, 141 
Hessee's method for test-tube culture, 353 
Heteralius, 67 
Heterotyphus, 67 

Hewson's preservative injection, 288 
Hexenmilch, 279 
Hey's saw, 29 
Hide-bound skin, 305 
Hide of an animal, removing of, 375 
Hip, congenital dislocation of, 3, 66, 266 



INDEX 



515 



Hip, diseases of, 66, 266. 301 

examination of, 444 
Hirshberg's method for test-tube culture, 

353 
Historical data on postmortems. 1 
Hodgkin's disease. 124 

effect upon mesentery. 160 
post-mortem findings in. 124. 125 
Hofmann's treatment of discoloration of 

decomposition. 52 
Homicide, 408, 411 
Horizontal plane, accepted. 361 

section of brain. 239 
Horse-flesh, 'now recognized. 300 
Hour-glass contraction of stomach, 90, 191 
Housemaid's knee. 273 
Human tuberculosis, 373 
Hume's intravenous injection of silver 

nitrate solution. 44 
Hutchinson's teeth. 78 
Hyaline defeneration. 129 
fixatives for, 340 
of arteries. 136 

pancreas. 222. 224 
Hydatids of liver. 458 
lungs, 155 
pleura, 156 
Hydremia. 116 
Hydrarthrosis, 262 
Hydrate, chloral, toxicology of, 425 
Hydrocele. 69 

gonorrheeal, 417 
mechanical, 417 
syphilitic. 417 
tuberculous, 417 
Hydrocephalic skull, 361 
Hydrocephalus, 249, 313 
Hydrochloric acid, toxicology of, 422, 427 
Hvdrocyanic acid poisoning, condition of 
eye in, 48 
post-mortem lividity in, 59 
toxicology of, 50. 411, 421. 425, 
430 
Hydrofluoric acid, toxicology of. 422. 427 
Hydrogen, arseniuretted. toxicology of, 
423 
peroxide of, 404 

sulphid, its action on blood, 19, 50 
Hydromeningocele. 249 
Hydronephrosis, 200 
Hydropericardium, 98 
Hydrophobia. 297. 373 
Hydrops bursarum, 273 
Hydrosalpinx, 208 
Hydrostatic test for lung, as sign of viable 

child. 404 
Hydrothorax, 156 
Hygroma, acute. 273 
Hymen. 69 

Hyoscyamine, toxicology of, 422. 423. 426 
Hyoscyamus, toxicology of. 422. 424 
Hyperemia, cerebral. 251 
hepatic. 219 



Hyperemia in croupous pneumonia, 152 

ot spleen, 1O3 
Hyperinosis, 115 
Hyperplasia ot mesenteric lymphatic 

glands in typhoid fever, ^16 
Hyperplastic osteitis, 270 
Hypertrophic bronchitis, chronic, 145 
cirrhosis, Hanoi's, 115 

of liver, 18, 217 
endometritis, chronic, 210 
gastritis, 192 

nasal catarrh, chronic, 141 
pulmonary osteo-arthropathy. 247 
rhinitis, chronic, 142 
vegetations, vaginal, 211 
Hypertrophy and atrophy in same part, 18 
concentric, of heart, 10O, 133 
congenital, 70 

eccentric, of heart, 106, 133 
general, 70 
of anus, 69 

arteries, 136 
clitoris, 69 
fingers and toes, 68 
glans penis, 68 
heart, 106, 133 

concentric, 106, 133 

eccentric, 106, 133 

in tuberculosis, 316 

most marked in double aortic 

disease, 106 
simple, 133 
marrow cells, 267 
ovary, 209 
prostate, 212 
scrotum, 69 
testicles, 69 
tongue, 68 
uterus, 209 
vulva, 69 
Hypinosis, 115 

Hypnotics, toxicology of, 421 
Hypodermic syringe in inoculation of 

animals, 383 
Hypoplasia, 249 
of aorta, 136 
testicles, 69 
uterus, 209 
Hypospadias, 68 

Hypostasis or hypostatic congestion, 49 
Hypostatic congestion, 40. 1 10 

pneumonia in typhoid fever, 318 
Hypsicephalic skull. 361 
Hysterectomy, vaginal, 281 
Hysteria, synonyms of, 453 



[card's tesl for possible presence of life, 

47 
Ichthyotoxismus, jtK 
Icteru 4=;8 

neonatorum, 458. 462 



;i6 



INDEX 



Icterus, odor in, 170 

ol \ ellovt Ee\ er, 319 
[ctrogen, toxicology of, 425 

[lupinotoxin] in animals, toxicology 
of, 423 
Identification of body. 53 

before beginning post-mortem ex- 
amination of, 53 
by Bertillon system, 53 
cast of face, 53 

of mouth, 53 
clothing, 54 
evidence of certain diseases, 

53 
photograph. 53 
physical defect or peculiarity, 

53 
scars, 53 
skiagraph of old osseous 

lesions, 53 
teeth, 53 
various aids. S3 
Idiocy. 249 

Idiopathic anaemia, 116 
Ileocecal valve, 166, 312 
Ileum of animals, removal of, 378 
Iliac fossa, phlegmon of, and appendicitis, 

synonyms of, 458 
Ill-defined diseases, 463 
Illuminating gas, toxicology of, 50, 411, 

431. 

Illumination at postmortem, 11 
Immunity to staphylococci and strepto- 
cocci, 43 
Impaction of gall-bladder, due to gall • 

stones, 216 
Imperforate anus, 279 
hymen, 69 
mouth, 68 
rectum. 279 
vulva, 69 
Inanition, 463 
toxic, 418 
Tnccnse. to remove odor, 10 
Incising heart, kidneys, etc., see under 

the various organs. 
Incision of organs. 20 
Incompetency, aortic, arteriosclerosis in, 

133 
Index, see p. 22 
Induration, cyanotic. 133 
Infant, autopsies on, 403 
Infanticide, methods of. 414 
Infantile scurvy. 126 

uterus. 209 
Infarct, anaemic, in spleen. 163 
bilirubin, 20T 

of heart, cause of sudden death, 
130 
spleen, 163 
hemorrhagic. 136 
of heart, 130 
of kidneys, 



Infarct of lungs, 148, 149 
mesentery, 160 
scurvy, 127 
uterus, 209 
syphilitic, 307 
Infections, gonorrhceal, 297 

local and general as cause of death, 

408 
paracolon, 319 
paratyphoid, 319 

purulent and septicemic, synonyms 
of, 449 
Infectious angina, see Diphtheria and 
Croup, 
diseases contracted at postmortem, 41 

of liver, 220 
fevers, 50, 202, 214, 218, 220 
as cause of death, 408 

of spontaneous abortion, 407 
processes, acute, fixative for, 338 
Infective aneurism, 138 
Infiltration, calcareous, 129 
of arteries, 135 
fatty, 129 

of liver, 18, 219 
pancreas, 221 
Infiltrations of heart, 129 
Inflammation, acute, of prostate, 212 
caused by poison, 426 
chronic, 262 
interacinous, 223 
of arteries, 136 
dura, 233 
lymphatics in post-mortem 

wounds, 44 
muscles, 83 
testicles, 211 
urethra, 69 
syphilitic, of veins, 140 
Inflammatory changes in joint, 71 

exudates, acute, fixative for, 338 
Influenza, 298 

gastro-intestinal form of, 299 
nervous form of, 299 
respiratory form of, 299 
Inguinal canal, examination of, 20, 73 
Injected specimens, 344 
Injecting fluid, 9, 288 

syringe for, 32 
Injuries, extent of, 20 
in violent death, 408 
location, etc., to be noted, 65 
minute description of, important, 408 
of vulva, 69 
overlooked, 20, yy 
to bones and joints, 267 

heart and pericardium, 99, 129 
Inner table of skull, examination of, 230 
Innominate vein, care not to injure, 93 
Inoculated tubes, cultivation of, 352 
Inoculating culture-media, 351 
Inoculation of animals, 353 
intravenous, 354 



INDEX 



517 



Inoculation of animals, intraperitoneal, 

354 
materials used for, S53 
media for, 352 
negative results from, cause 

of, 353 
preventive caution needed in. 

site of. 356 

subcutaneous. 354 
tube containing medium. 352 
Inoculum, avoidance of contamination of, 
353 
preparation of. S53 
Inorganic chemic poisons. 420 
irrespirable gases. 420 
irritant poisons. 420 
Insolation, 463 
Inspection of body. 13. v, p. 46 

special organs in animals. 395, 3Q6 
Instruments, care of. for bacteriologic ex- 
amination, 346 
for bacteriologic investigations, 347 
post-mortem examinations of 

large domestic animals, 374 
private post-mortem work, 35 
post-mortem, and how to use them. 
iii, p. 28; 374, 446 
necessary, 28 
proper handling of, 36 
sterilizing of, 352, 356 
to be taken to postmortem, 35 
various, 32 
Insular sclerosis. 254 

Insurance. American, standard of weight. 
. 358. 

in accident company, 45 
Interacinous, chronic, inflammation. 223 
Intercarotid bodies, 112, 260 
Interlobular pleurisy, 158 
Interments, premature. 46 
Intermittent fever and malarial cachexia. 

synonyms of. 448 
Internal anthrax. 291 

evidence- of period of development of 

infant, 405, 406 
examination in postmortem. 439 
of brain. 234 

lower animal >. scheme for 
recording 394 
International system of nomenclature of 
diseases and causes of death, xxviii. p. 
448 
Interstitial, chronic, pancreatitis 221 
nephritic 199. 201 
pancreatitis 221 
pneumonia, 223 
Intestinal adhesion-, 85 

content-, removal of. 286. 443 
hemorrhage, as a complication of ty- 
phoid fever. 448 
legions of typhoid fever. 318 
obstructions and hernias 457 



Intestinal parasites. 457 

perforation, as a complication of ty- 
phoid fever, 448 
plague, 301 

tract, gall-stones and worms in, 170 
Intestines, adenoma of, 171 
agglutinated, 165 
bucket method of opening and 

cleansing, 167 
carcinoma of, 171 
contraction of, 165 

diseases of, 126, 127. 151, x, p. 159; 
217. 219, 291, 292, 293, 299, 304, 306, 
308, 311, 317, 318, 319, 320, 408, 411, 
426, 428, 430, 431, 432, 433 
distention of, 165 
examination of, 14, 15, 164, 440, 443 

in animals, 376, 383 
faeces in, 169 
fibroma of, 171 
hernia of, 159 
inflammation of, 159 
large, diseases of, 165, 166, 167, 318 
examination of, 164, 165, 166, 167, 

442, 443 
measurements of, 366 
removal of, 166, 443 

in animals, 380, 382 
tumors of, 171 
weight of, 366 
ligation of, for removal, 165 
lipoma of, 171 
measurements of, 366 
method of opening, 166 

removing from body, 165 
myoma of, 171 
opening and cleansing of, 166 

of, in animals, 383 
other affections of, 457 
parasites of, 170 
perforation of, 164 
polyps of. T/i 
removal of, 15. 165,288 , 443 

in animals, 380, 382. 383, 393 
sarcoma of. 171 

-mall, diseases of. 165, 308, 311, 432 
examination of, 15. 104, 165, 166, 

167. 442, 443 
measurements of, 366 
removal <>f, 15. 166, 443 

in animals, 380, 382, 393 
tumor- of, 171 
weighl of. 366 
stricture of. 306 
tuberculosis of, 311. 312 

tumor- of. 171 

weight of. 366 

worms in, 170 
fntima of carotid-, torn, in death from 

strangulation, 112 
Intoxication-, trade or occupation, 452 

Intraperitoneal inoculation of animals, 354 
[ntra-uterine gestation, period of, .405. 444 



ci8 



INDEX 



Intravenous injections, 44 

inoculations, 354 
Intussusception, 172 
Invagination, 00. 01 
Inversion of bladder, 206 

eyelids, 73 
Investigations, bacteriologic, xxiii, p. 346 
lodin stains, how removed, 286 

therapeutic use of, 44 

toxicology of, 21, [26, 422, 423. 431 
Iodoform for post-mortem wounds, 43 

toxicology of, 21, 421 
Ipecacuanha, toxicology of, 422 

Iritis. 297, 306 

Iron of haemoglobin decomposed by hy- 
drogen sulphid, 19 

tripods, 32 

useful in axillary cellulitis, 44 
Irrespirable gases, organic and inorganic, 

420. 421 
Irritability, muscular and nervous, loss of, 

how determined, 47 
Irritant inorganic poisons, 420 

organic poisons, 421 

poisons, 420. 421 
Irritating dusts, toxicology of, 422 

vapors, toxicology of, 422 
Nchiopagus, 67 

Islands of Langerhans in diabetes, 223, 224 
Itch. 461 
Itch-mite. 320 



von Jaksch's anaemia, 124 

Jalap, toxicology of. 424 

Jar-, quart, museum, for specimens, 34 

Jaundice, 153 

appearance of skin in, 60 

in eyes, 74 
Jaw. deformities of, 257 

examination of articulation of, 260 

necrosis of, 434 
Jejunum of animals, removal of, 378 
Jigger, 319 

Johnson's mixture, 257 
Joint, condition of, in gout, 128 

Charcot's, 284 

cricoarytenoid, ankylosis of, 143 

diseases of. 72. 126. 127. 153, xvii, p. 
26] : 293, 297. 299. 303, 305, 419 

empyema of, 261 

examination of. 14, 261, 439 

fa 1m 

foreipn bodies in. 267 

inflammation of. 261 

injuries to, 267 

removal of, 261 

rheumatism of, 303 

tumors of, 261. 263 
Jumbo, weight of heart of, 365 
Jumping from high places, suicide by, 463 



Kairin, effect on urine, 425 

Kaiserling fluid, 343 

Karorosis of vulva, 69 

Karyokinesis, fixation of tissues for, 33J 

Keratitis, 74 

Kidney, abnormality of, 20, 199 

absence of, 199 

adrenal tissue in, 204 

amyloid changes in, 199, 307 

angiomata of, 204 

anthrax of, 292 

atheromatous, 179 

calculi of, 204 

capsule of, examination of, 178 

carcinoma of, 204 

sarcomatodes of, 204 

cholera Asiatica of, 293 

color of, 178, 179 

concretions in, 200 

congenital cystic, 200 
defects in, 199 

congestion of, 199, 200 

cortex of, relation of, to medulla, 179 

cystic disease of, 200 

cysticerci of, 202 

decapsulation of, 3, 179 

degeneration and regressive processes 
in, xi, p. 199 

dimensions of, 368 

diseases of, 64, 85, 98, 99, too, 116, 117, 
126, 127, 128, 132, 135, 136, 142, 144, 
145, 151, 153, xi, p. 166; 217, 220, 
291, 293, 294, 295, 299, 300, 303, 304, 
307, 311, 313, 323, 407, 408, 410, 411. 
418, 426, 427, 428, 431, 434, 435, 459 

distoma haematobium of, 202 

echinococci of, 202 

examination of, 14, 178 

fibromata of, 204 

fibrous changes of, 199 

filaria sanguinis of, 202 

floating, 175 

granular, 179 

horseshoe, 199 

incising of, 178 

infarcts in, 200 

in postmortem, 442 

interstitial nephritis of, 201 

lesions in, in scarlet fever, 304 

lipomata of, 204 

liver-tissue in. 204 

lobulation of, 199 

lymphadenomata of, 204 

lymphomata of, 204 

measurements of, 368 

method of opening, 177, 178 

removing from body, 176 

movable, 202 

myomata of, 204 

myxomata of, 204 

opening of, 178 



INDEX 



519 



Kidney, parasites in, 202 

parenchymatous nephritis of. 202 

pentastoma oi. 202 

poisons especially affecting, 41S 

ratio of weight of, to that of body. 368 

removal of, 38, 04, 170. 177. 275. j8o. 
442, 444 
in animals, 356, 380 

rhabdomyomata of, 204 

right and left, distinguishing points 
between, 368 

sarcoma of. 204 

scars oi, 179 

specific gravity of, 368 

stones in. 204 

strongylus gigas of, 202 

syphilis of. 308 

traumatism oi, 199 

tuberculosis of, 311, 314 

tumors of. 179. 204 

vascular changes in, 199 

weighing of, 179 

weight of. 177, 179, 360. 367 
Killing of animals for necropsy, 374 
Klebs-Loffler bacillus, 14;. 293 
Knives, 28 

amputation. 29 

brain. 29 

curved, probe-pointed bistoury. 29 

pointed, danger of, 37 

section or cartilage, 29 

Valentine. 29 

Waring's, 29 
Knock-knee. 71. 268 
Koch's inoculation syringe, 353 
Kolisko. 8 
Kreotoxismus. 418 
Kromskop. its usefulness, 18 
KupfTer's cells of liver, 224 
Kyphosis 198. 246, 269 



Labelling ti^ue< preserved for micro- 
scopic purposes. 327 
Labor, normal. 460 
Lacerations. 17. 20, 69 
Lack of care as cause of death, 462 
Ladles. 33 

Landmarks, regional, 17 
Lardaceous degeneration. 144 
Large intestine, see Intestines, large. 
Laryngeal cavities exposure of. 256 

diphtheria, 294 

stenosis, 143 
Larynpi^ pachydermia, 143 
Laryngitis acute catarrhal, 142 

chronic. 142 

diphtheritic. 142 

nedematou-, 142 

«icca. 143 

syphilitic. 309 

tubercular. 315. 449 



Larynx, carcinoma of, 143 

deformity of. 142 

diseases oi. 07. 128. 141, 142. 133, 146, 
240. 204. 297, 200. 300. 305. 306. 307,. 
309, 31-'. 315. 3l8, 455 

epithelioma of, 143 

erysipelas of, 142 

examination of. 1 ;.. 15. 442. 445 

exfoliation oi the cartilages oi. 143 

fibroma tuberosum of, 143 

lupus of, 318 

papillary fibroma of, 143 

papilloma in. 143 

perichondritis of. 143 

removal of. ^y, 442 

sarcoma of, 143 

syphilis of. 307, 309 

tuberculosis of. 315 

tumors of. 143 

ulcerations of, 143 
Lateral sinus, thrombosis of, 112 
Lathy rism, 418 
Lavatories, 12 

Law permitting post-mortem examina- 
tions, 5 
Lead, toxicology of. 411. 420. 422, 423, 
424. 425, 431 
in animals, 421, 422. 423. 424 
Length and weight of a full-term sound 

child, 358 
Lenhossek's stain, 341 
Leontiasis ossea. 70, 247 
Leprosy, 299 

anaesthetic form of, 299 

synonyms of, 449 

tubercular form of, 299 
Leptocephalic skull, 361 
Leptomeningitis. 139. 2^, 253 

acute purulent cerebrospinal, 251 

chronic deep, 253 
diffuse. 253 
Lesions, see diseases of the various or- 
gans. 

cortical. 237 

distribution of, 16 

suggestive, 16 
Letullc'- method of making postmortem, 

15 
Leucocythasmia, Mood changes in. 123 

complications of. 452 

effect on mesentery, 160 

lymphatic, 124 

medullary. 123 

mixed. 124 

pseudo-, 124 

specific gravity of blood in. 114 

Spleni 

;, t - . - 1 - . 117 

Leukopenia, 117 

Leukaemia, rthaania. 

Library. 12 

11 body, method of quickly re- 
move I 



INDEX 



Ligaments, diseases of, 73, [28, 262, 268 
Light, artificial, 8 
Lightning, death by, 49, 4 [ 3 
Limb, atrophy of, 56 

examination of, 438 

shortening of, 56 
Lime, deposits of, in colloid goitre, 96 
Lindsay Johnson's mixture, 257 
Lion-forceps, 32 
Lipaemia, 117 
Lipoma, arborescent, 263, 273 

of bone, 273 
eye, 75 
heart. 134 
intestines, 171 
kidney. 204 
peritoneum. [$g 
pleura, 156 
vulva, 69 
Lips, diseases of, 68, 141, 295, 296, 307 
Liquefaction of lungs, 153 
Literature, xxix, p. 465, and many foot- 
notes and references in the text 
Lithography and three-color printing, 18 
Lithopiedion, 208 
Lithosis, [55 
Liver, abscess of, 213, 219 

aberrant adrenal tumors of, 220 

accessory, 367 

acidity of, 418 

acute yellow atrophy of, 213 

adenocystomata of, 220 

adenomata of, 220 

adrenal tissue in, 91, 220 

after tight lacing, 91 

amyloid degeneration of, 214, 307 
fixative for, 340 

and gall-bladder, 193, 213 

angioma of, 220 

anthracotic cirrhosis of, 217 

appearance of, in cholera Asiatica, 293 

atrophic cirrhosis of, 216 

atrophy of, acute yellow, 213 

bile capillaries of, fixative for, 340 

cancer of, 214 

capsular cirrhosis of, 217 

carcinomata of, 220 

cirrhosis of, 216, 217, 224, 417, 427, 458 

color of, 195 

congestion of, 218 

consistency of, 195 

cyanotic cirrhosis of, 217 

dimensions of, 367 

discolorization of, in ammonium hy- 
drate poisoning, iq 

diseases of, [8, 20, 01, 65, 66, 85, 86, 

94. 95, 112, Il6, T22, 124, 127, 135, 

140, 144. 145. 148, 151, 153, 161, 174. 

I89, TQO, 200, 201, xii, p. 213; 22T, 
222. 223, 246, 280. 293, 295, 300, 302, 

301, 307. 308, 309, 3", 313, 317, 318, 
310, 323. 324. 408, 411, 418, 427, 428, 
431. 433, 434 



Liver, ducts of, diseases of, xii, p. 213 

echinococcus of, 322 

emphysema of, 218 

examination of, 14, 15, 91, 193, 194, 
195, 276, 442, 443, 444 

exenteration of, in animals, 381 

extra lobes of, 91 

fatal hemorrhage from, 65 

fatty changes in, 218 
cirrhosis of, 217 
degeneration of, 218 
infiltration of, 18, 219 

fibromata of, 220 

fixatives for, 340 

flukes, 321 

hemorrhage from, 20 

hepatitis of, 219 

hydatid tumors of, synonyms of, 458 

hyperemia of, 219 

hypertrophic cirrhosis of, 18, 217 

in cholera Asiatica, 293 

general tuberculosis, 313 

infectious diseases of, 220, 293 

inflammation of, 219 

injury to, 219 

in postmortem, 443 

laceration of, from external violence, 
20 

lobules of, 195 

lymphoma of, as a lesion in typhoid 
fever, 318 

malarial cirrhosis of, 217 

measurements of, 367 

method of removing from body, 193 

multiple abscess of, 219 

of animals, excision of, 379 

other affections of, 458 

parasites of, 220 

passive congestion of, 218 

pernicious anaemia, fixative for, 340 

poisons especially affecting, 418 

position of, 195 

primary cancer in, 215 

psorosperms in, 323 

removal of, 15, 193, 194, 275, 443, 444 
in animals, 356, 381, 393 

rhachitic cirrhosis of, 217 

sarcoma of, 16 

scarlatinal cirrhosis of, 217 

secondary cancer in, 214 

specific gravity of, 367 

supernumerary, 91 

syphilis of, 309 

syphilitic cirrhosis of, 217 

tumors of, 16, 214, 215 

volume of, 367 

weight of, 360, 366, 367 
Lividity, cadaveric, cause of, 49 

color of, 49, 50 

degree of, depends on fluid condition 
of blood, 50 

distinguished from beginning decom- 
position, 50 



INDEX 



521 



Lividity, cadaveric, distinguished from 
bruise, 49. 50 
in sunstroke, 414 
location of. 49 
maximum time of, 49 
post-mortem, 49 
rose-red color of, 50 
time of appearance of, 49 
Lobar pneumonia. 151, 152 
Lobeline, toxicology of. 422. 424 
Lobular pneumonia. 151. 154. 299 
Lobulation of kidney. 199 

pancreas. 221 
Locomotion, diseases of organs of, 461 
Locomotor ataxia, 248. 452 
Longevity of bacterial spores, 356 
Longitudinal sinus. 123, 231, 277 
Loose bodies in joint, 265 
Lordosis, 197. 269 
Lorenz operation, 3 
Louse, 319 

Luer's rhachiotome, 242 
Lugol's solution. 214 
Lumpy jaw, 290 
Lungs, abscesses of, 147 
adenoma of, 155 
air embolism of, 148 
anaemia of, 148 
apoplexy of, 148 
atelectasis of, 147 
brown induration of, 179 
cancer, secondary, of, 155 
carcinoma of. 155 
changes in color of, 97 
chondroma of, 155 
circulatory disturbances of, 148 
cirrhosis of, 155 
color of. at different ages, 97 
cut surface of, 109 
in heart disease, 109 
normal, 109 
congenital, changes in. as blood is 

oxidized. 276 
congestion of, 19, 148 
c'onsolidation of, 109 
contraction of, 97 
dermoid cysts in, 155 
dimensions of. 366 

diseases of, 16. 20, 61, 65, 67, 72, 80, 
85, 94. 95. 97, 98. 99, 100, 109, no, 
123. 126, 127, 128, 132, 138, 139. 140, 
ix. p. 147: 190. 200. 223, 246, 247, 
252. 261, 269. 270, 272, 290, 293, 294, 
296. 299, 300, 301. 302, 303. 308, 309, 
311, 312. 315. 3l8, 324. 408. 431. 433- 
4.34- 435 
emphysema of. 149. 4" r > 
examination of. 14. 15. 97. 108. no. 
152. 276. 280, 441, 442, 444- 445 
in animals. 385 
expanded, appearance of. 97. 276 
fat emboli ~m of. 148 
fibroma of. 155 



Lungs, gangrene of, 150, 456 
haemoptysis of, 148 
hemorrhage of, 148 
hydatids in, 155 
hypostatic congestion of, 149 
in animals, dissection of, 385 
-incising of, 108, 109 
infarcts of, 148, 149 
malignant growths of, 155 
measurements of, 366 
microscopic examination of, 109 
oedema of, 149 
osseous formations in. 155 
osteoma of. 155 
palpation of, 109 
parasites in, 151 
pneumonic consolidation of, 151 
pneumonoconiosis of, 155 
post-mortem appearances of, in deter- 
mining viability of child, 404 
purulent oedema of, 145 
removal of, 15, 95, 107, 280, 441 

in animals, 356, 382 
specific gravity of, 366 
spindle-celled sarcoma of, 156 
superficial examination of, 97 
suppuration of, 153 
syphilis of, 309 
traumatism of, 155 
tuberculosis of, 147, 311, 312, 315 
tumors of, 155 
colloid, 156 
encephaloid, 156 
epitheliomatous, 156 
scirrhous, 156 
unexpanded, appearance of, 276 
weight of, 109, 360, 365 
Lung-tissue, hemorrhage into, T48 
Lupinotoxin, toxicology of, 423 
Lupus vulgaris, 318 
of larynx, 318 
vulva, 69 
Luxations, 266, 463 

Lymph, collections of, mistaken for other 
lesions, 89 
tumors, 140 

vessels, diseases of, \iii. p. 140 
Lymphadenitis in scarlet fever, 304 
Lymphadenoma, 124, 204 
Lymphangeitis, 69. 153 
Lymphangioma, 140 

Lymphatic glands, diseases of, 16. 44. 66, 

80. 04. 116. 123. 124. 125, 140, 

[.S3, 190, 224, 201. 203. 294. 295, 

297. 301. 304. 306. ,V)7. 316. 455 

examination of. [5, 6l, 66 

involvement of, in post mortem 

wound 
mediastinal, pigmentation of, 95 
nteric, hyperplasia of. in ty- 
phoid fever. 318 
mistaken for melanotic larcoma, 



34 



5 22 



INDEX 



Lymphatic glands, new growths of, 196 

of axilla, inflammation of, in post- 
mortem wounds, 44 
removal of, in animals, 356 
retroperitoneal, examination of, 

196 
tuberculosis of, 316 
tumors of, 41, 140 
system, affections of, 455 
vein, great, 15 

\ressels, examination of, 442, 443 
Lympho-carcinoma in mediastinum, 146 
Lymphocytosis, diseases present in, 116 
Lymphoid marrow, 267 
Lymphoma in mediastinum, 146 
of kidney, 204 

liver, a lesion in typhoid fever, 

3i8 
tonsils, 143 
Lymphosarcomatosis of heart, 134 
Lymphotoxaemia in new-born, 279 
Lymph-vessels, carcinoma of, 140 
dilatation of, 140 
endothelioma of, 140 
lesions of, 140 
syphilis of, 140 
tuberculosis of, 140 
Lysol, effect on urine, 425 



M 



Macrocytosis, 117 
Microglossia, 140 
Macroglossus, 68 
Macroscopic specimens, examination of, 

341 

preservation of, xxii, p. 326 
Macro^toma, 68 
Magnifying-glass, 33 
Magnus's test of circulation, 48 
Malachite green, toxicology of. 422 
Malacia, 223 
Malaria. 322. 373 

restivo-autumnal. 322 

eruptions in, 62 

pernicious, 322, 323 

quartan, 322 

simple, 322 

tertian, 322 
Malarial cachexia. 323 
chronic. 322 

cirrhosis of liver. 217 

fever. 322 
Mai dc caderas, 324 

Male fern, toxicology of, 422 

Genital tract, examination of. 185, 211 
Malformations as cause of death, 408 
due to di^ea^e, 462 
in anaemia, 72 
aneurism. 72 

chronic lung condition. 72 
nervous diseases, 72 



Malformations of nose, 141 

osteitis deformans, 72 
osteomalacia, 72 
rhachitis, 72 
syphilis, 72 
testicles, 69 
tuberculosis, 72 
Malignant angina, see Diphtheria. 

disease, see Cancer of various organs, 
pustule, 291, 449 
Mallets, 31 

Mallory's anilin-blue stain, 324 
Malpractice, 397, 398 
Malta fever, 300 
Mammary glands, 81 

colostrum in, 81 
fibrous tissue in, 81 
incisions in, 81 
lactation of, 81 

of new-born, secretions in, 279 
tuberculosis of, 317 
tumors of, 61 
Manometer, 47 
Marantic thrombi, 136 
Marrow, atrophy of, 267 

cells, hypertrophy of, 267 
changes in, in osteomyelitis, 267 
fatty degeneration of, 267 
in children, appearance of, 267 

middle life, appearance of, 267 
lymphoid, 267 
method of fixing, 338 
Mask, death, 289 

Massage, stiff joints prevented by, 44 
Mast-cells, fixative for, 340 
Mastoid disease, 246 
Materials, collection of, for culture pur- 
poses, 346 
used for inoculation, 353 
Maturity and period of intra-uterine ges- 
tation determined at postmortem, 444 
Maxilla, alveolar compartments in, 405 
Maxillary glands, weight of, 366 
Maximum weight of encephalon, 361 
McKinley, postmortem on, 6 
Measles, 300, 351, 448 
complications of, 4^8 
German, 300, 303 
Measures and weights, xxiv, p. 357. See 

also various organs. 
Mechanical congestion, 149 

hydrocele, 417 
Meckel's diverticulum, 165 

typhoid ulcer in, 19, 20 
Meconium, 214, 278 

Media for isolation of pathogenic micro- 
organisms, 350. 351 
Mediastinal adenitis, simple, 146 
suppurative, 146 
tuberculous, 146 
hemorrhage, 95 
Mediastinitis, 146 
Mediastino-pericarditis, 95 









INDEX 



523 



Mediastinum, abscess of, 95 
carcinoma of, 146 
dermoid cysts of, 146 
diseases oi, 94, 95. 99, 146 
emphysema of, 95 
examination oi, 95, 441 
lympho-carcinoma of, 146 
lymphoma of, 146 
tuberculosis of, 95 
tumors of. 66, 95, 100, 146 
Medical examiners. 1 

men as experts, 400 
Medicine, practice of, compensation in, 

398 
Medicolegal and pathologic postmortems, 
difference between. 402. 437 
cases, medical men as experts in, 400 
Prussian regulations for per- 
formance of autopsies in, xxvii, 
p. 436 
examinations, 53 

postmortem examinations, form of re- 
port in, 403 
in cases of poisoning, 402. 443 
references, xxix. p. 474 
suggestions, xxvi. p. 397 
Mediterranean fever, 300 
Medulla oblongata, diseases of, 253. 297 
examination of, 236, 439 
removal of, 236 
incising of. 236 
weight of, 362 
pons, and basal ganglia, fixatives for, 

339 
Medullary cancer of stomach, 190 

leukaemia, 124 
Melanin, effect on urine, 425 
Melanosarcoma of lungs, 156 
Melanosis, arsenical, toxicology in. 422 
Melanotic sarcoma of pericardium. 99 
diagnosis of, 99 
of heart. 134 
Melnikow-Raswedenkow fluid. 343 
Membrane, diphtheritic, 294 
false, of diphtheria. 294 
mucous, appearance of. in hydropho- 
bia. 297 
condition of. in cholera Asiatica, 

293 
preservation of. 327 
serous, preservation of. 327 

tuberculosis of, 317 
spinal, hemorrhage of, 251 
Membranous, chronic, nasal catarrh, 141 

coliti-. 174 
Mendel's law, a law of heredity experi- 
mentally shown to exist by Mendel in 
1865 and but recently rediscovered, in 
which one-fourth of the charact< 
will be like each parent and the other 
half will - 
Meniere'? disease, aural vertigo. 
Meningeal hemorrhage. 251 



Meningeal plague, 301 

Meninges, diseases of, 14. 10. [28, [32, 25r, 

252, 253, -09. 301, 313, 40S. 411 
Meningitis, acute cerebrospinal, 2^2. 408, 

448. 452 
Meningocele, 68, 75 
Meningoencephalitis, 10. 253, 313 
Menorrhagia. 128 
Mental alienation, forms of, 453 
Mentha pulegium, toxicology of. 424 
Menthol, effect on urine, 425 
Merbane, 411 
Mercaptan, odor of, 21 
Mercurial poisoning, toxicology of, 418. 

421. 422. 423. 424. 425. 426. 432 
Mercury, bichlorid of, for fixing tissues, 

333 
Mesenteric artery, superior, thrombosis of, 
137 
glands, diseases of, 89, 90, 160, 293, 
306, 318 
examination of, 89, 160 
hyperplasia of, in tvphoid fever. 
'318 
tumors of, 160 
Mesentery, disease of. 86, 159. 160, 317 
examination of, 14, 15, 159. 160, 442 
shortened, 160 
tumors of, 86. 160 
Metabolism, carbohydrates in, 222 
Metals, acid salts of, toxicology of, 424 
Metapagus, 67 

Metastasis due to cancer of stomach, 190 
Methaemoglobinsemia. 419 
Method, angular, of removing calvarium, 
226 
author's, of examining male genital 
organs, 186 
fixing skull-cap. 284 
preparing frozen section-. 12 
removing brain in child. 276 
testing gums for lead. 423 
circular, of removing calvarium. 
Dejerine's, of examining brain. 238 
external, of examining testicles, 186 
French, of opening adult skull. 228 

dura. 228 
Giacomini's, of examining brain. 241 
Hamilton's, of examining brain, 
flarke's. of examining nasopharynx, 

256 
Letulle's, of removing organs, [5 
Meynert's, of examining brain. 
closing abdominal incision, . 
committing suicide, 
cutting rib- of animals, 377 

diagnosing 1 

dividing the dura. 231 
embalming cavities, 286 
injecting embalming fluid. 
killing domestic animals for 
mortem examination, 374 



5 2 4 



INDEX 



Method oi loosening adherent dura, 227 
calvarium, 227 
making a death-mask, 289 

post-mortem examination of 

animals, 355 
smear preparations, 349 
opening and cleansing intestines, 
166 
brain, 239 

canal of W'irsung, 188 
cephalic cavities of horse, 387 
intestines, 166 
kidney, 177, 178 
oesophagus, 188 
spinal canal, 242 
stomach, 188 
performing autopsy without vis- 
ible mutilation, 280 
criminal abortion, 406, 407 
infanticide, 414 
postmortems on animals, 
xxiii, p. 346; xxv, p. 373 
preserving natural color of speci- 
mens, 344 
removing adrenal, 176 
brain, 232 
calvarium, 226 
child's brain, 276, 277 
extremities of an animal, 375 
hide of an animal, 375 
intestines from the body, 165 
kidney from the body, 176 
liver from the body, 193 
male organs of generation, 

l8 5 
posterior extremity of an ani- 
mal. 375 
spinal cord, 242 

from body of baby, 277 
spleen, 162 
replacing scalp, 285 
restoring and preserving the body, 
283 
skull. 283, 284 
sectioning brain, 235 
Pitres's, of examining brain, 237 
quick, for removing brain, 233 
Virchow's. of examining brain, 235 
Methyl alcohol, toxicology of, 21, 432 
Methylene blue, effect on urine, 425 
Metritis. 459 
Metrorrhagia, 128 
Meynert's method of examining brain. 

235. 239 

Micrencephaly. 249 
Microbic poisoning, 16 
Microcephalic skull, 361 
Micrococcus gonorrhoeae, 350 

melitensis, 300 
Microcytosis, 117 
Microglossia, 68 
Mirromegaly, 247 
Mirromyelia, 24Q 



Micro-organisms, diseases due to, xxi, p. 
290 
in appendicitis, 171 
peritonitis, 160 
pathogenic, media for isolation of, 

350, 35i 
present at postmortem, 43 
Microscopic examinations in postmortem, 

438 
specimens, preservation of, xxii, p. 326 
study, preservation of tissues for, 326 
Microsomia, 70 
Microstoma, 68 
Middle ear, 258, 304 

Miliary, acute, tuberculosis of brain and 
cord, 313 
aneurism, 138 
carcinosis, 160 
fever, 351 

tubercles, lymph mistaken for, 89 
of adrenals, 180 
heart, 134 
peritoneum, 89 
ureter, 182 
tuberculosis,' 311, 312, 313, 315 
of lungs, 311 

peritoneum, 317 
serous membranes, 317 
Milk spots, 151 

Mineral acids, toxicology of, 424, 426 
Mitral, buttonhole of, 133 

diseases of, 103, 129, 133, 303 
examination of, 101, 103 
orifice of heart, dimensions of, 365 
stenosis, 133 
Molar death, 326 
Molecular death, 326 

necrosis, 262 
Moles of uterus, 209 
Mollineux trial, 55 
Mollities ossium, 270 
Monoxid, carbon, toxicology of, 425 
Monsters, 67 
double, 67 

parasitic, 67 
single, 67 
triple, 67 
Morbidity statistics, xxviii, p. 448 
Morbilli, see Measles. 
Morgue, 9 
Morphine, 65, 418 

administered before electrocution, 413 
toxicology of, 413, 418, 421, 422, 423, 
424, 425 
Morphinism, toxicology in, 421 
Mortopsy, see Postmortem. 
Mortuary room, 10 
Morvan's disease, 452 
Mosquitoes, anopheles, 322 

as disseminators of dengue, 373 
malaria, 373 
yellow fever, 319, 373 
stegomyia, 319 



INDEX 



525 



Mouth and its adnexa, diseases of, 60, 64, 
67, 68. 294, 295, 296, 301, 309. 310, 
312. 420. 428. 432, 456 
examination of, 53, 60, 281 
Movable kidney, 202 
Mucoid material, fixatives for, 340 
Mucous fever, see Typhoid fever. 

membrane, appearance of, in hydro- 
phobia. 297 
condition of, in cholera Asiatica, 

297 
of corpse. 47 

stomach, action of poisons on, 
419 
patch. 69. 306, 307 
Muller's fluid for fixing tissues, 234, 257, 

Multipara?, weight and dimensions of 

uterus in, 371 
Multiple abscess of liver, 219 
Mummification. 49 
Mumps. 301. 351 
Murexid test for tophi, ^3 
Muscarine, toxicology of. 422, 423, 424 
Muscle-fibres, preservation of, 327 
Muscles, atrophy of. due to rheumatism, 
303 
progressive spinal, 253 

color of, in anaemia, 82 

contracture of. disappearance of, 
after death. 71 

diseases of. 63, 72, 82, 83, 94, 253, 254, 
292, 297. 303. 305, 306, 318, 321, 416, 
428. 431, 432. 433, 444 

examination of, 63, 81, 444 

external examination of. 61 

hemorrhages in, 82, 318 

inflammations of, 83 

involuntary, post-mortem contraction 
of. 49 

irritability of, loss of, 47 

lesions in, 82 

papillary, 129 

parasites in. 83 

syphilis of, 306 

tumors in, 83, 84 

twitchings of, in amputated limbs, 47 

waxy degeneration of, in typhoid 
fever, 318 

weight of, 360 
Museum, 12 
Mustard, oil of, 422 
Mycobacterium leprae. 299. 350 

tuberculosis 350 
Mycotic aneurism, 138 

gastritis. 192 
Myelin sheaths fixatives for, 339 

litis, acute. 254 
Myelc »eases present in, 116 

Myelomeningocele, 249 
Myelotome. Pick's, 29 
Myiasis, 321 
Myocarditis, 130 



Myocarditis, acute circumscribed inter- 
stitial, 130 
associated with pneumonia, 153 
chronic interstitial, 131 

pathologic changes in, 131 
diffuse interstitial, 131 
due to rheumatic fever, 303 
fibroid, 133 
fibrous, 131 
parenchymatous, 130 
segmentary, 130 
Myocardium, examination of, 105 
Myoma of bladder, 205 
intestines, 171 
kidney, 204 
tonsils, 143 
vulva, 69 
Myomalacia cordis, 131 

of heart, 130 
Myositis, acute, 83 
chronic, 83 
parenchymatous, 83 
progressive ossifying. 83 
Mytilotoxismus, 418 
Myxoedema, 147 

presence of thymus gland in, 95 
Myxoma, fixatives for, 340 
of bone, 274 
brain, 2" 
heart, 134 
kidney, 204 
nasal passages, 141 



N 
Nagana, 324 
Nails, 77 

anomalies of, 77 
diseases of, 77, 307 
examination of, 77, 444 
growth of, 77 

matrix, suppuration of, how treated, 
45 
Name, legal, for record, S3 
Narcosis, chloroform, death from, 198 
Narcotics, toxicology of, 421, 424 
Nasal and cranial cavities of ruminant, 
lines used in sawing, 390 
catarrh, acute. 141 
atrophic, 141 
chronic, 141 
fibrinous. 141 
hypertrophic. 141 
membranous, mi 
cavities, exposure of, 256 

diphtheria. 204 

fossae, angiosarcoma in, 141 

carcinoma in, 141 

chondroma in. 141 
disease of, r r 

passages cysts in, 141 
diseases of, T41 

epithelioma in. 141 



526 



INDEX 



Masai passages, fibroma in, 141 
fibromyxoma in, 141 
foreign bodies in, 142 
osteoma in, 141 
rhinoliths in, 141 
sarcoma in, 141 
tumors in, 141 
tuberculosis. 141 
Nasopharynx, 274, 294, 299 

examination of, 14, 233, xvi, p. 256; 
282 
in animals, 389 
Natator gyrinus, toxicology of, 426 
Native Africans, variations in color of 

skin of, 60 
Nauwerck's method of embalming, 287 

discovering seminal vesicles, 

l8 7. 
Navel, .sec Umbilicus. 
Xeck, diseases of, 71, 72 

dislocation of, 66 

examination of, 66, 71, 72, 112, 438, 
442, 444 
in postmortem, 440, 442 

fracture of, 66 

inspection of, 66 

tracheal fistula of, 68 

visceral clefts of, cysts of, 68 
Necropsy, see Postmortem. 
Xecrosis, appearance of bone in, 268 

centralis, 268 

diffuse. 268 

fat, 196. 221, 222 

molecular, 262 

phosphorous, 268 

superficialis, 268 
Necrotic alteration, 296 

changes in bone, 267 
Needles, 33 

tarnishing of. in living muscle, 48 
Negri bodies, 419 
Nematodes, 321 

Neoplasms, malignant, of cervix uteri, 211 
Nephritis, acute, 458 

diffuse, in scarlet fever, 304 
in typhoid fever, 318 

as cause of death, 408 

chronic, 407 

diffuse, 223 

epithelial, 199 

fibrous, 199 

interstitial, 199. 201 

parenchymatous, 199. 202 
Nephrolithiasis, see Calculi, renal. 
Nerium. toxicology of, 424 
Nerve, ischiatic, section of, 51 
Nerves, spinal, 243 

sympathetic, hemorrhage into, 112 
Nervous form of influenza, 299 

irritability, loss of, how determined, 
47 

system, central, action of poisons on, 
4T0 



Nervous system, central and peripheral, in 
alcoholism, 427 
fixatives for, 338 
other diseases of, 453 
Nettles, toxicology of, 422 
Neuralgia, synonyms of, 453 
Neurofibroma of brain, 255 
Neurogenous arthritis, 264 
Neuroglia fibres, 255, 339 
Neuroretinitis, 223 
Neuroses, as cause of death, 408 
New-born, examination of, post-mortem, 

275, 444 

lymphotoxsemia in, 279 

post-mortem examinations of, xviii, 
p. 275 

secretion in mammary glands of, 279 

urine of, study of, 278 
New growths, see also tumors of various 

parts, 21 
Nicotine, toxicology of, 421, 422, 423, 424 
Nipple, accidental vaccination of, 61 

infection of, 61 

Paget's disease of, 61, 324 

supernumerary, 61, 81 
Nissl's staining methods, 234, 241, 341 
Nitric acid as a fixative of tissue, 336 

toxicology of, 422, 423, 426 
Nitrite, amyl, toxicology of, 425 

sodium, toxicology of, 423, 425 
Nitrobenzol, toxicology of, 21, 411, 423, 

432 
Nitrogen dioxid, toxicology of, 422 
Nitroglycerin, toxicology of, 423 
Nodular arteriosclerosis, 135 
Nodules of sarcoma in omentum, 159 
Noma, a form of diphtheritic gangrene. 
Nomenclature of diseases and causes of 
death, international system of, xviii, p. 
448 
Non-venereal diseases of genital organs 

of male, 459 
Nose, abnormal shapes of, 68 

absence of, 68 

deviation of septum, 68, 141 

diseases of, 68, 70, 128, 141, 142, 252, 
296, 297. 290, 308, 405, 427, 444 

malformations of. 141 

saddle-back, 68 

septum of, deviation of, 141 

tumors of, 141 
Note-book, 23 
Notes to be made during postmortem, 23 

dictation of, 22 

mistakes in, liability of, 23 

value of, 23 
Note-taking at autopsy, 22 
Nothnagel's method, 235 
iV-rays in diseases of cord, 404 
Nuck, canal of, ovary in, 69 
Nutmeg poisoning, toxicology of, 433 
Nutrition and weight, 59 
Nux vomica, toxicology of, 426 



INDEX 



527 



Obducent in medicolegal postmortems, 

401, 402 
Obducrion. 2 
Obesitas cordis. 129 
Objects oi medicolegal postmortems, 401 

used for comparison, 18 
Obligations oi a patient to physician. 398 
Obliterative appendicitis, 172 

arthritis. 250 
Obstructive endarteritis. 136 
Occlusion or absence of urethra, 69 
Occupations, inflammations of skin in cer- 
tain, 63 
Ochronosis. 22^. 264 

Odor, characteristic, oi certain diseases, 21 
from postmortem, to remove, 10. 40 
of acetone in diabetes, 21 

alcohol from brain. 21 

ammonia. 21 

amyl nitrite. 21 

aromatic oil, 418 

bacterial growths. 21 

Bacterium coli commune. 21 

benzene. 418 

bromin, 21 

bromoform. 21 

camphor, 418 

cancerous ulcerations, 21 

carbolic acid, 21, 418 

certain poisons 21 

chloral, 418 

chlorin. 21 

chloroform. 21 

chlorphenol. 21 

creosote, 21 

drugs. 21, 418 

ether. 21 

ethereal oils, 21 

formalin, 21 

hydrochloric acid, 418 

hydrocyanic acid, 21 

iodin. 21 

iodoform. 21 

measles. 21 

mercaptan. 21 

methyl alcohol. 21 

nicotine, 418 

nitrobenzol. 21 

opium. 21 

organs. 21 

paraldehyde, 21 

phosphorus, 21 

>n. detection of, on exposing 
brain. 419 

; n leucocythremia. 21 

smallpox. 21, 300 

sulphuretted hydrogen, 418 

tellurium. 21 

turpentine. 418 

uraemia. 21 
mortem, 10. 286 



(Edema. 20 

complicating croupous bronchitis, 145 

of glottis, 423, 426, 448 
larynx, 142 
lungs, 408, 423 

purulent, 145 
vulva, 69 
pulmonary, 149 
(^Edematous condition:, fixatives for. 340 
infiltration, post-mortem, 50 
laryngitis, 142 
(-Esophageal epithelium, 189 
CEsophagus, abscesses of, 190 

dimensions and weight of. 366 
diseases of, 99, 112, 190, 295, 297, 310. 

312. 42O, 457 
diverticula of, 190 
examination of, 14, 15. ()(). 188, 189, 

442. 444 
in animals, dissection of, 384 
measurements of, 189, 366 
obstructions of, 112 
peptic ulcers of, 190 
removal of, 15, 96, no, 189, 442 

in animals, 381 
stricture of, 190, 227 
syphilitic ulcers of, 190 
tongue, trachea, and adjacent struct- 
ures, removal in one piece and sub- 
sequent examination of, no 
tuberculosis of, 312 
tuberculous ulcers of. tqo 
tumors of, 112, 190 
typhoid ulcers of. 190 
ulcers of. 190 
weight of, 366 
Office of coroner, 1 

Ohlmacher's solution for fixation of tis- 
sues, 334 
Oidium albicans, 310 
Oil, anilin, toxicology of. 421 

croton, toxicology of, 422. 423. 424 

curcas, toxicology of, 422 

ethereal, of mustard, toxicology of. 

422 
of turpentine, effect on urine, 424 
poley. toxicology of. 423 
Olygremia, 116, 163 

Omentum and peritoneum, fixation of, 337 
appearance of. in peritonitis, 88 
diseases of, 89, 160, 220. 317 

minatiofl of. 14. 15, 88. 159, 442 
fat in, 89 
fish-bone in, 20 
hernia of. 89, [59 
miliary tubercle- in. 150 
nodule- of sarcoma in, 1 59. 
openings ii 

removal of 

situation 1 
tumors of, 89, [60 

VOlvuluS Of, ' -') 

Omphalomesenteric duct. ^ 



528 

Omphalopagus, 67 

Omphalositic monsters, 67 

Onychia, 306, 307 

Opening of abdominal cavity, technic of, 

vi. p. 70 
thoracic cavity, technic of, vii, p. 

02 

Openings oi urethra, abnormal, 69 
Operating table, dimensions of, 11 
( operation, Loren; . 3 

Operative technic of postmortems upon 
animals, 374 

Operator, position of, in post-mortem ex- 
amination of abdominal cavity of an 
animal, 376 

Opinion, provisional, of obducent, at close 
of postmortem, 446 

Opium, toxicology of, 21, 4"> 4 2I > 422, 

424, 433 

Optical differentiation in preservation of 

unties, 329 
Optic nerve, 75 

thalamus, examination of, 439 
Oral cavity, examination of, 281 

section of, in animals, 384 
Orbit, examination of, 71 

fractures of. 76 
Orbital diseases, 76 
Orcein stain, 341 
Orchitis, 310 
Order in a judicial hanging, 46 

of examination, ii. p. 13 
Organic acids, salts of, toxicology of, 424 
used as fixing fluids, 329 ■ 

alkaloidal poisons, 421 

chemic poisons, 421 

diseases of heart, 454 

excitomotor alkaloidal poisons, 421 

irrc-^pirable gases, 421 

irritant vegetable poisons, 421 
animal poisons, 421 

narcotic alkaloidal poisons, 421 

poisons, 421 

sedative alkaloidal poisons, 421 

synthetical poisons, 421 

toxinic poisons, 421 
Organisms, specific, diseases due to, 351 
Organs, abdominal, discoloration of, 19 

anomalies and malformations of, 17 

borders of, 16 

cervical, in animals, section of, 384 

changes in borders of, 18 

characteristics of, 16 

color of. 18 

changes by exposure to air, etc., 
19 

consistency of, 17, 19 

contour, 16 

coverings of, 16 

cut surfaces of, and liquid exuded 
from. 20 

dislocation of, 17 

double, how distinguished, T7 



INDEX 



Organs, external appearance of, 18 

histological structure of, suggests pos- 
sible lesions, 21 
incisions into, 13 
internal, table of approximate weight, 

360 
measuring of, by means of a steel 

rule, 360 
method of designating, upon removal 

by surgeon, 66 
new growths in, 21 
odor from, 17, 21 

both before and after 
opening, 357 
of abdominal cavity, critical examina- 
tion of, 159 
generation, male, removal of, 185 
locomotion, diseases of, 461, 462 
pathologic conditions of, 21 
pelvic, in animals, removal of, 385 

in postmortem, 442 
scraping of, 20 

sections of, for preservation, 327 
shape, etc., of, 16, 18 
situation of, 16 

and relation to other parts, 17 
size and weight of, 17 
solid, culture from, 352 
special, in animals, inspection of, 395, 

396 
supernumerary, 91 
thoracic, in animals, dissection of, 384 

and abdominal, removal of, 15 
to be weighed before opening, 357 

after opening, 357 
various, weighing of, table of Letulle, 
357 . . 
Orifices, aortic, dimensions of, 365 
mitral, dimensions of, 365 
of heart, dimensions of, 365 
pulmonary, dimensions of, 365 
tricuspid, of heart, dimensions of, 365 
Orthocephalic skull, 361 
Orthognathous skull, 361 
Orthopaedic deformities, 268 
Orth's fluid in preservation of tissues, 257, 
.. 328, 333, 335 
Ose, 34, 352 
Osier's disease, 124 
Osmic acid as a fixative, 329, 336 

toxicology of, 422 
Osseous formations in lungs, 155 
system, examination of, 26 
tumors, 273 
Ossification, centres of, in child, 278, 40^ 

of ligaments, 269 
Osteitis, 269 
caseosa, 270 
deformans, 72, 247, 270 
hyperplastic, 270 
purulent, 270 
rarefying, 269 
Osteo-arthropathies, 270 



INDEX 



5 2 9 



Osteoarthropathy, hypertrophic pulmo- 
nary, 247 
Osteochondral line in syphilis, examina- 
tion for, 277, 405 
Osteoma, 273 

of lungs, 155 

nasal passages, 141 
pleura, 156 
Osteomalacia, 72, 270 
Osteomyelitis, 267 
Osteophytes. 255. 263, 273 
Osteoporosis, 264, 270 
Osteopsathyrosis, 265 
Osteosclerosis, 269 
Otitis media, 153 
Otocephalus, 67 
Ounces, 357 
Ovarian cysts, 209 

at navel, 66 

tumors, 209 
Ovaries, adenomata of, 209 

atrophy of, 209 

cysts and other tumors of, synonyms 
of, 459 

dermoid cysts of, 209 

dimensions of. 371 

diseases of, 66. 208, 301 

examination of, 14, 15, 442 

fixatives for, 340 

follicular degeneration of, fixative for, 
340 

hypertrophy of, 209 

in canal of Nuck, 69 

measurements of, 371 

pathologic changes in, 208 

removal of, 184 

in animals, 386 

supernumerary, 66, 77, 181, 208 

transplantation of, 3 

tumors of, 209 

weight of, 360, 370 
Oviducts, 207, see also Fallopian tube. 
Oxalic acid, toxicology of, 411, 419, 424, 

425, 426, 427 
Oxamid, toxicology of, 424, 426 
Oxybutyric acid, toxicology of, 421 
Oxycephalic skull, 361 
Oxygen, exclusion of, from culture media, 
349, 552 

starvation, 415 
Oxyuris vermicularis, 321 
Ozaena, organisms of, 293 



Pacchionian bodies in temporal bones, 265 
Pachycephalic skull, 361 
Pachydermia laryngis, 143 
Pachymeningitis, 230, 233 

hemorrhagic. 162 
Paget's disease, 61, 324 
Pails. 34 



Palate, cleft, 68 

deformities of, 257 
" Pale," use of word in pathology, 19 
Palms of hands, color of, in corpse, 47 
Palpation of an organ, 19, 109 
Paludal fever, see Intermittent fever and 

Malarial cachexia. 
Paludism, see Intermittent fever and Ma- 
larial cachexia. 
Panaricium, 268 
Panarthritis, 261 
Pancreas, accessory, 220 

Altmann's granules, fixation for, 340 

anatomy of, 196 

anomalies of, 220 

apoplexy of, 221 

atrophic changes in, 196 

calculi in, 196 

cancer of, 196 

cysts in, 196 

degenerations of, 196 

dimensions of, 369 

diseases of, 91, 117, 190, 196, xii, p. 
220 

examination of, 14, 15, 196, 442 

exenteration of, in animals, 381 

fat necrosis of, 196, 222 

fatty infiltration of, 221 

fixatives for, ^40 

hemorrhages in, 196, 221 

hyaline degeneration of, 222 

lobulation of, 221 

measurements of, 369 

position of, 196 

removal of, 15, 91, 196, 224, 381 
in animals, 379 

specific gravity of, 369 

syphilitic periarteritis of, 222 

tumors of, 91, 190, 196 

weight of, 360, 369 
Pancreatic duct, examination of, 188 

hemorrhage, 221 

tissue, accessory, 91, 188, 196, 220 
Pancreatitis, acute, 220 

chronic interstitial, 221 

congenital syphilitic, 221 

gangrenous, 220 

hemorrhagic, 220 
Panniculus adiposus, 59 
Papillary cystadenoma, 146 

excrescences of trachea, 146 

fibroma in larynx, 143 

muscles, 129 
Papilloma in larynx. 143 

of tonsils, 143 
Parabanic acid, toxicology of, 424 
Paquelin thermocautery, 35 
Paracephaln-. 67 
Paracolon infections, 3 '9 
Paraffin, injection of. to restore parts, 3 
Paraglobulin, no 
Paragonimus Westermanii, 321 
Paraldehyde, toxicology of, 21 



530 

Paralysis complicating scarlatina, 448 
diver's, see Caisson disease, 249 
general, synonyms of, 453 
Paralytic dementia, 248 
Paramidophenol, effect on urine, 425 
Paraphenylendiamin, toxicology of, 412 
Parasitic haemoptysis, 321 
Parasites, diseases due to, xxi, p. 319 
double, 07 
in bladder, 207 
blood, [21 
bones, 274 
kidneys, 202 
liver, j jo 
lungs, 151 
muscles, 83 
intestinal, synonyms of, 457 
in ureters, 205 
of brain, 255 
liver, 220 
Parathyroids, discovery of, 96 
internal secretion of, 97 
number of, 96 
situation of, 96 
structure of, 96 
tumors of, 97 
Paratyphoid fever, 169 

infections, 319 
Parchment -like spots, 65 

due to drying, acids or alkalies. 65 
Parenchymatous myocarditis, 83. T30 
myositis, 83 
nephritis. 199. 202 
chronic, 203 
subacute, 202 
Parotid gland, 260, 269, 301, 302, 306, 366, 

439 
Parotitis, 306 
Patella, removal of, 444 
Pathogenic micro-organisms, media for 
isolation of, 350, 351 
organisms, danger from, 6 
Patient and physician, contract between, 
397 
obligations of, to a phvsician, 398 
physician to, 397 
Pectus carinatum, 7T 
Pediculus capitis, 319 
corporis, 319 

getting rid of. at postmortem, 59 
pubis, 319 
Pelade^. 461 
Pellagra, 351. 418. 440 

toxicology of, 421. 425, 433 
Pelvic oreans, [83 

in postmortem, 4/12 
removal of. in animals. 385 
Pelvimeter, 35 
Pelvis, exenteration of. in animals, 385 

female, characteristics of, 59 
Penal offence to conceal death of illegiti- 
mate child, 55 

illium brevicaule, 21 



INDEX 



Penis, absence of, 68 

arteriosclerosis of, 68 

atresia of, 68 

atrophy of, 68 

cancer of, 68 

diseases of, 68, 70 

elongation of, 68 

erection of, 68 

examination of, 68 

fissure of, 68 

gangrene of, 68 

hypertrophy of, 68 

imperfect formation of, 68 

phimosis of, 68 

removal of, 185, 186 

scars on, syphilitic, 68 

tumors of, 68, 134 
Pennsylvania Hospital, Ayer Clinical 

Laboratory of, no 
Pentastoma of bladder, 207 

heart, 134 
Pentastomum denticulatum of spleen, 164 
Pepper dust, toxicology of, 422 
Peptic glands, examination of, 444 

ulcer, 169 

ulcers of oesophagus, 190 
Percentage of water in foetus and adult, 

360 
Percussion, pathologic conditions revealed 

by, 66 
Perforating ulcer of foot, 248 
Perforation, by poison, 426, 427 

due to ulcer of stomach, 87 

in typhoid fever, 319 

of intestines, 164 
Performance of autopsies in medicolegal 
cases, Prussian regulations for, xxvii, 
P- 436 
Periarteritis nodosa, 139 

syphilitic, of pancreas, 222 
Periarthritis, 261 

Peribronchial gland, caseating, 134 
Peribronchitis, 146 
Pericarditis, 99, 144 

complicating pneumonia, 99, 153 
rheumatic fever, 303 
scarlatina, 448 

gonorrhceal, 297 

productive, 99 

suppurative, 99 

synonyms of, 454 

tuberculous, 99 
Pericardium and heart, injuries to, 99 

changes in, at autopsy, 19 

diseases of, 95, 98, 99, 144, 146, 151, 
153, 174, 291, 295, 297, 299, 302, 303, 
304, 311, 323, 445 

erosion of, in suppuration of, 99 

examination of, 13, 14, 15, 98, 441 
in animals, 384 

heart, blood, blood-vessels, and 
lymph-vessels, viii, p. 113 

in animals, examination of, 384 






INDEX 



53 1 



Pericardium, method of opening, 98 
normal amount of fluid in, 98 

appearance of, 99 
tumors of, 99 
Perichondritis. 143 
Perilymphangeitis, 153 
Perinephritic abscess, 203 
Period of maturity in intra-uterine gesta- 
tion. 405. 406. 444 
Periosteal sarcomata. 274 
Periosteum, conditions of, in necrosis, 268 

in rickets. 2~2 
Periostitis. 208. 271, 281 
Peripheral nerve-fibres, fixative for. 339 
disease- of. 248, 250. 254, 292, 297, 
299 
Perithelioma of brain, 255 
Peritoneal fluid, specimen of, from inocu- 
lated animals, 163 
Peritoneum, actinomycosis in, 159 
cancer of, 160 
cysts in, 159 

diseases of, 84. 85, 86, 89, 132, 144, 153. 
160, 161, 165, 174, 189, 190, 217, 220, 
291, 311. 317. 323, 411, 443 
endothelioma in, 159 
examination of, 14. 15, 84. 159, t6o 
fibromata in, 159 
filaria in. 159 
lipomata in, 159 
mechanical irritation of, 3 
method of examination of, 88 
pulmonary tissue in, 159 
tuberculosis of, 317 
tumors of, 159, 160 
Peritonitis. 144, 153 
acute general, 160 

serous, 161 
as a complication of tvphoid fever, 

448 
cause of, 161 
chronic. 161 

diffuse adhesive, iot 
diffusive adhesive. 161 
fibrinous, 161 
hemorrhagic, 161 
in typhoid fever, 310 
local adhesive. 161 
micro-organisms in. t6o 
proliferative. t6i 
purulent, 161 
putrid. 161 
-erofibrinou-. l6l 
simple, synonyms of. 458 
tuberculous adhesion- in. 85 
ulcerative, 161 
Periurethral abscess from gonorrheal in- 
fection. 297 
Permission to perform postmortem. 3 
method of obtaining, 3 
to remove portion- of body for 
ervation. 5 
PernicK'Ui ana-tnia. 121, [05 



Pernicious cachexia, see Malarial ca- 
chexia, 
fever, see Intermittent and Malarial 

fever, 
malaria, see Malarial cachexia. 
Peroxid of hydrogen, 404 
Pest, 449 

Petechial fever, see Exanthematous ty- 
phus. 
hemorrhages, 145, 192, 414, 428 
spots, 171 

typhus, see Exanthematous typhus. 
Petroleum sprees, poisoning therefrom, 

412 
Peyer's patches, 123, 125, 293, 295, 301, 

305. 443 
Pfeiffer's bacillus, 298 
Phalloides, amanita, 418, 424 
Pharyngeal cavities, exposure of, 256 

diphtheria, 294 
Pharynx, affections of, 141, 246. 296, 297, 
308, 456 
examination of, 15, 442 
removal of, no, 442 
Phenomena bearing upon future of pathol- 
ogy, 404 
Phenylendiamin, toxicology of, 422 
Philadelphia Hospital, postmortems at, 5 
blank post-mortem record of, 26 
Phimosis of glans penis, 68 

partial, of urethra, 69 
Phlebectasia, 140 
Phlebitis of veins, 139 
Phlebosclerosis. 140 

Phlegmasia alba dolens, puerperal, com- 
plications of, 460 
Phlegmon of iliac fossa, 458. 461 
Phlegmonous gastritis, 191 
Phloridzin, toxicology of, 425 
Phosphates and lime salts in bones of 

pregnant women, 70 
Phosphomolybic acid hematoxylin, 341 
Phosphorescence, as a pathologic force, 

404 
Phosphorescent bacteria, 404 
Phosphoric acid, useful in axillary cellu- 
litis, 44 
Phosphorism, toxicology in. 423 
Phosphorus, necrosis from, 268 

toxicology of. 21. 41 t, 421. 423, 424, 

' 425, 433 
Phosphotungstic acid hematoxylin, 341 
Phrenic nerves exposure of, 98 
Phthisiogenic organism. 350 
Phthisis, fibroid. 311. 315. 316 

florida. 311. 315 

ulcerative. 311. 315 
Physician and patient, contrad between. 
397 

obligations of patient to, 398 

to patients, 307 
practising, when intoxicated, ;i crimi 

nal offence. 398 



532 



INDEX 



Physician, resident, 3, 6 
Physicians certificate for return of a 
death, 404 

responsibility in judicial hanging, 46 
Physostigmine, effect on pupil after sud- 
den death, 46 
toxicology of, 421, 4_'_\ 423, 424 
Pia and arachnoid, weight of, 362 
diseases of, 244. 251, 252, 313, 434 
removal of, 231, 241 

in animals, 388 
Pianese's solution, as a fixative, 337 
Pick's myelotome, 29, 232 
Picrates, toxicology of, 422, 423, 424 
Picric acid, as a fixative, 327, 337 

toxicology of, 423, 424, 433 
Picro-acetic acid, as a fixative, 2>2>7 
Picro-hydrochloric acid, as a fixative, 337 
Picro-nitric acid, as a fixative, 337 
Picro-sulphuric acid, as a fixative, 337 
Picrotoxin. toxicology of, 421, 434 
Pig, as a disseminator of trichinosis, 373 
Pigeon-breast (pectus carinatum) of rha- 

chitis, 72 
Pigmentation in chlorosis, 122 
Pigments in bile, 214 
Pilocarpine, toxicology of, 422, 423, 424, 

426 
Pineal gland, dimensions and weight of, 
363. 
examination of, 236 
Pins, 33 

Pitres's method of examining brain, 235, 
237 
studying centrum ovale, 235 
Pituitary body, 56, 70, 246, 247, 282, 363 
removal of, through orbit, 247 
Place at which a postmortem is made, 8 
Placenta, diseases of, as causes of spon- 
taneous abortion, 407 
weight of, 359 
Placental polyp, 209 
Plagiocephalic skull, 361 
Plague, bubonic, 301, 449 

carbuncular, 301 
Plague-corpuscle, 301 
Plague, intestinal. 301 
meningeal. 301 
pneumonic, 301 
septic. 301 

subcutaneous hemorrhages due to, 302 
" Plaques choriales" of sheep, 70 
Plasma cells, fixative for, 340 
Plaster of Paris 289 

for filling cranial cavity, 34 
in the preservation of the 
body. 283 
Plastic bronchitis, 145 
Plastron, fit;. 69 
Plates, earthenware, 33 
Platinico-acetico-osmic-acid solution, 336 
Platinum loop, or ose, 347. 348 
Platycephalic skull. 361 



Plethora serosa, 115 

vera, 115 
Pleura, abscess of, 144 
carcinoma of, 156 
chondroma of, 156 

diseases of, 95, 97, 99, 127, 140, 144, 
146, 147, 149, 153, 155, 156, 157, 158, 
174, 190, 219, 291, 293, 295, 297, 299, 
301, 316, 416 
endothelioma of, 156 
examination of, 97, 108, 441 
fibroma of, 156 
hyatid cysts of, 156 
interlobular, 158 
lipoma of, 156 
osteoma of, 156 
sarcoma of, 156 
teratoma of, 156 

thickening of, as lesion in tuberculo- 
sis, 316 
tuberculosis of, 156, 315 
tumors of, 156 

visceral, pathologic conditions of, 108 
Pleural cavity, amount of fluid in, 97 
empyema of, 156 
examination of, 97 
suppuration in, 156 
Pleurisy, 156, 157 
acute, 157 
chronic, 157 
dry, 157 
diaphragmatic, 158 
due to rheumatic fever, 303 
encysted, 158 
following dysentery, 174 
gonorrhceal, 297 
hemorrhagic, 157 
primitive dry, 158 
purulent, 157 
synonyms of, 456 
Pleuropneumonia, 151 
Plexus, choroid, 439 
Pneumococcal arthritis, 264 
Pneumococci, 146 
Pneumococcus (Streptococcus lanceola- 

tus), 351 
Pneumogastric nerves, 15, 276 
Pneumomalacia, 150 
Pneumomycosis, 151 
Pneumonia, 151 

as a complication of typhoid fever, 
318, 448 
cause of death, 408 
bacillus of, 151 
catarrhal, 151 

and croupous, difference between, 
154 
chronic interstitial, 151, 152, 223 
croupous, 151, 152, 223 

and catarrhal, table showing dif- 
ference between, 154 
due to rheumatic fever, 303 
fibrinous, 151, 152 



INDEX 



533 



Pneumonia, hypostatic, in typhoid feyer, 
3i8 
lobar, 151, 152 
lobular, 151, 154, 299 
stages of, 152 
synonyms of. 456 
Pneumonic areas in tuberculosis, 316 

plague, 301 
Pneumonoconiosis, 155 
Pneumonopericardium. causes of, 99 
Pneumothorax. 156 
localized. 156 

method of detecting. So, gS 
Pockets in walls of bladder, 206 
Podagra. 263 

Podophyllotoxin, toxicology of, 424 
Poikilocytosis, 117 

Poisons, see Toxicology of the various 
poisons themselves. 
classification of. 420 
definition of, 417 
Poley oil, toxicology of. 423 
Poliomyelitis, acute anterior, 254, 351 

from compression, 254 
Polycythemia rubra, 116 
Polydactylism, 2 
Polygnathus, 68 
Polymelus, 68 
Polyps of intestines, 171 
rectum, 69 
ureters, 204 
uterus. 204 
Pons Varolii, diseases of, 313 

examination of, 236, 439 
fixatives for, 339 
incising of. 236 
removal of, 236 
weight of, 362 
Porencephalon. 250 

Porencephaly, external and internal, 249 
Portal pyaemia, 219 

vein, 15, 61, 139, 162, 193, 194, 196, 365 
Post, see Postmortem. 
Posterior extremity of an animal, method 
of removing, 375 
sclerosis, see Locomotor ataxia. 
Posthumous circulation, 49 
Post-mortem books, 25 

changes in conjunctiva, 48 

cornea, 48 
color scale, method of using, 113 
considerations general, i. p. 1 : 436 
cooling, hastened by use of water. 49 
rectal temperature after forty 

hours, 49 
time required for completion. 49 
decomposition, 49, 52 
digestion of stomach. 87 
drain-. 11 
emphysema, 95 
examination of animal 
bird-. 304 
cats 392 



Post-mortem examination of dogs, 392 
law permitting, 5 
lower animals, 374 
new-born, 275, 403 
restricted, 280 
ruminants, 389 
swine, 391 
order of, and records, 13 
rules for, 13 
expulsion of foetus, 46 
instruments, and how to use them, 

iii. p. 28 ; 439 
lividity or cadaveric lividity, 49 
note-taking, ii, p. 13 
odor, 286 

records, ii, p. 13 ; 22, 23, 24, 26. 27, 394 
of findings in lower animals, 394 
references, xxix, p. 465 
report, 447 

rigidity or death-stiffening, 50 
room, 10 

drains of, 11 
latticed flooring for, 12 
ventilating shaft for, 11 
table. 9, 11 

measuring rod for, 11 
portable, 9 
revolving, 1 1 
weighing body on, 11 
transportation of corpses, 437 
wounds, care of, iv, p. 38 

caustics used in treatment of, 43 
how caused, 42, 43 
virulence of, 41, 42 
Postmortem, abdominal cavity in. 442 
after electrocutions, 7 
Anatomical Board and, 5 
anatomy, study of. at, 3 
appearance of parts improved after. 
ascertainment of special circum- 
stances in, 437 
assistants at, 6 
at hospital, 9 
morgue, 9 
private house, 9 
undertaker's. 9, 10 
Boards of Health and. 4 
care in handling specimens removed 

at, 6 
cases of poisoning in. 443 
Cause of death, determined by. 16 

in child, whether or not 
it has breathed, 444 
cleanliness at, 
closure of body in, 445 
comparative, >cxv, p. 373 
cranial cavity in, 430 
death-stiffening 

imposed bodies in, examination 
of. 436 

defendant represented at, 420 

definition of, 2 
diagnosis at, 16 



534 



INDEX 



Postmortem, disinfection after, 2 
dress at, 10 

clinic- of obducents in, 437 
early, in America, 1 
establishment of judicial, 1 
external examination in, 438 

of decomposed bodies, 436 
new-born, xviii, p. 275 
vertebrae, as medicolegal 
precaution, 402 
frozen bodies in, 437 
general considerations, i, p. 1 ; 436 
historical, 1 
illumination at, II 
in charitable institutions, 5 
France, 6, 10 
Germany, 5, 7 
insurance cases, 4, 5 
medicolegal cases, Prussian regu- 
lations for performance of, 436 
internal examination in, 439 
interval to elapse before making, 7,, 

436 
intra-uterine gestation in, 444 
kidneys in, 442 
laboratory, upon animals, 374 
law permitting, 15 
legal right to perform, 3 
Letulle's method of making, 15 
light at, 8 
liver in, 443 
medicolegal, 401, 437 

and pathologic, difference be- 
tween, 402 
definition of, 2 
in cases of poisoning, 402 

treatment of contents of 
stomach, 402 
duodenum and ileum, 402 
each organ, 402 
obducent in, 401 402 
objects of, 401 
order of performing, 14 
micro-organisms present at, 43, xxiii. 

P- 346 
microscopic examinations in, 438 
multiple. 11 
neck in, 442 
nurse at. 6 
object of, 2 

odor at. removal of, 10, 286 
of Bishop, 7 

Brooks, Phillips, 6 
McKinley. 6 
on anatomical ca 

animals, operative technic of. 374 
babe-, suspected of hereditary 

■lilis, 277 
birrK, 304 
bones, 261 

302 
child, preparation for. 
302 



Postmortem on ears, 256 
eyes, 256 

horse, 374 

infants, 403 

joints, 261 

lower animals, value of, 373 

nasopharynx, 256 

new-born, 444 

ruminants, 389 

swine, 391 
operations at, 3 
order of examination at, 13 
pelvic organs in, 442 
performed in coffin, 9 

without legal permission, 3 
performing of, dangerous, 45 
permission to perform, 3 

method of obtaining, 3 
persons present at, 6 
physicians and their duties in, 436 
place at which made, 8 

for and its lighting, 437 
portable table for, q 
precautions to be taken in performing, 

401 
preparation for, 9 

prevention of rheumatism while per- 
forming, 12 
prohibition of smoking at, 6 
Prussian regulations for the perform- 
ance of medicolegal, xxvii, p. 436 
purpose of, 2 

record books for, form of, 24, 26, 394 
records of, ii, p. 13 
references to, xxix, p. 465 
removal of entire organs at, 15 
odor at, 10 
specimens at, 5 
repetition of, 420 
report of, 447 

resident physicians making, 3, 6 
restricted, xix, p. 280 
rigidity in, 50 
room for, 11 

fittings of, 11 
rules for performing, 13 
scales at, 10 

scheme for record of, in lower ani- 
mals, 394 
skull at, 10 

small and large intestines in, 443 
societies for performing, 4 
spinal column and cord in, 440 
spinal cord in, 242 
spleen in, 442 

stomach and duodenum in, 443 
stool for instruments at, 12 
study of normal structures in, 2 

anatomy at, 3 
synonyms of, 12 
substitute for daylight at, 8 
substitutes in, 436 
suggestions at, 6 



INDEX 



535 



Postmortem, surgical procedures at. 3 
synonyms of, 2 
technic of, 437 

thoracic cavity in. 440 
those present at. 

time after death before making. 7. 430 
for performance oi. 7 
of completing a. 7 
to be made before the body is dressed, 

8 
transportation of corpses for. 437 
two main divisions of, 438 
undertaker at. 6 
value of, in accident cases. 2 
veterinary, xxv. p. 373 
where made. 9 

wounds in. treatment of, iv. p. 38 
Post-partum hemorrhage. 128 
Potassium, bichromate of, as a fixing 
fluid. 331 
toxicology of, 8 
binoxalate, toxicology of. 424. 420 
cantharidate. effect on urine, 426 
cantharidinate. effect on urine, 424 
chlorate, toxicology of, 60. 203. 423. 

4- 7 5- 434 
cyanid. toxicology of. 411. 419. 421 
Pott's disease. 72. 108. 450 

complications of. 450 
Powder markings. 409 
Powerful convulsive remedies, toxicology 

of, 421 
Pregnancy, accidents of. 460 

ectopic, ovarian, tubal, 207 
Premature interments. 46 

belief in. in Munich, 46 
labor, case of. 279 
Preparation of inoculum, 353 

material in a sterile bulb for in- 
oculation. 3^3 
smear. 347 
Preservation of body. xx. p. 286 

disembowelled bodv of child. 276 

muscle-fibres, 327 

serous and mucous membranes. 

127 
.titties, by alcohol. 338 
cedar oil. 338 
nitrate solution. 338 
gar formation in liver. 

• *■ • 

tor macroscopic purposes, 320 

microccooic c tudy. 326 
general considerations in. 342 
Preservative injection for embalming 
bodies. 287 
fluid 
Primitive dry pleurisy. 1 ^8 
Principles, active, of digitalis. tox : 

of. 421 
Probe 



Prognathous skull. 301 

Progressive locomotor ataxia, synonyms 
of, 452 

muscular atrophy, 253 
Prolapse of rectum. 69 

vagina. _' 1 1 
Proliferative endarteritis. 136 

chronic peritonitis, 1O1 
Prosopothoracopagus, 67 
Prostate, abscesses oi, 212 

cystic formation in, 212 

dimensions of, 372 

diseases of, 205, 212, 297, 459 

enlargement of, 212 

examination of, 14. 13. 186, 212. 442 

inflammation of. 212 

measurements of, 372 

removal of, 185. 186 

tumors of, 212 

weight of, 372 
Prostatitis, gonorrhceal. 297 
Prostration. 4O3 

Proteus, see Bacterium vulgare, 350 
Protocol of postmortem 22, 445, 446 

in animals, 394 
Protozoa, diseases due to, 351 
Protozoon of smallpox, 305 
Provisional opinion of obducent, at close 

of postmortem, 446 
Prussian regulations for medicolegal au- 
topsies. 7. xxvii. p. 436 
Psammosarcoma of brain, 255 
Pseudencephalos, 67 
Pseudoarthrosis, 266 
Pseudoleukemia, 124 

Pseudomembranous angina, see Diphthe- 
ria and Croup. 
Pseudomuscular hypertrophy. 253 
Psilosis, 306 
Psoas muscles, 14, 198 
Psorospermiasis, 323, 324 
Psorosperms in liver, 323 
Ptomain and toadstool poisoning, toxicol- 
ogy of, 434 
Ptosis, acquired or congenital, 73 
Puerperal accidents, other. 460 

diseases of the breast, 460 

eclampsia, 270 

and albuminuria, 460 

latest theory of cause of, 278 

hemorrha.L" 

scarlatina, see Scarlatina. 

septicemia. 460 
Pnlcx irritans, 310 

penetrans 310 
Pulmonary abscess, 213 

apo] 

art- • [02, loj. 105. 1 10. 148. 

150, 22.7. ■ 
congestioi 
of typhoid 

embolism. 148 
reden 



536 

Pulmonary orifices of heart, dimensions 
of, 365 

osteoarthropathy, hypertrophic, 247 

roots, 13, 1 10, 441 

thrombosis, 14S 

tissue below diaphragm, 91 
in peritoneum, [59 

valves, [5, [33, 365 

veins, thrombosis of, 148 

vessels, examination of, HO 
Pulse, absence of, on palpation, 47 
Pupils, contraction oi, after death, 48 

dilatation of, after death, 48 

in death by electricity, 413 

measurement of, 74 

Ripault's test on, 48 
Purpura, 125 

cachectic. 126 

forms of, 126 

hemorrhagica, 120 

Henoch's. 126 

iodic. 126 

mechanical, 126 

morbid anatomy of. 126 

neurotic, 126 

rheumatica, 126 

simplex. 126 

toxic, 126 
Purpuric blotches mistaken for bruises, 

126 
Purulent and septicemic infection, 449 

bronchitis in typhoid fever, 319 

oedema of the lung, T45 

osteitis, 270 

periostitis. 268, 271 

pleurisy, 157 

vulvitis (gonorrhceal), 69 
Pns in post-mortem wounds, treatment of, 
43 

or purulent conditions, fixatives for, 
340 
Putrefaction, by poison, 427 

early manifestations of, 49 

in sunstroke, 414 

most positive sign of death, 49 
Putrid bronchitis, 144, 145 
Pyaemia, chronic specific, 297 

portal, 219 
Pyaemic hepatitis, 219 
Pyelitis and pyelonephritis, 203 
Pyelonephritis, 203 
Pylephlebitis, 149 
Pyloric stenosis, [90 
Pylorus, [90 
Pyopagu 

eumothorax, 150 

epticaemia, 219 
• >rax, [56 
Pyramid. Lalouette's, 96 
Pyramidon, toxicology of, 425 
Pyrogallic acid and caustic soda for ab- 
sorption of oxygen. 353 

'I'll, toxicology of. 423, 425 



INDEX 



Quartan malaria, see Intermittent fever 

and Malarial cachexia. 
Questions, medicolegal, 400, 409 
Quillaja bark, toxicology of, 422 
Quinine, toxicology of, 422, 425 
useful in axillary cellulitis, 44 



Rabic tubercle, 298 
Rabies, 297, 351, 449 

method of diagnosing, 298 
Race, 55 

Racial characteristics, 58 
Rachipagus, 67 

Radio-activity of dead body, 404 
Ranunculus acris, toxicology of, 422 

sceleratus, toxicology of, 422 
Rape,- evidence of, 54 
Rarefying osteitis, 269 
Rash of smallpox, 305 

rose, 351 
Raspatory of Chiara, 31 
Rat, disseminator of bubonic plague, 373 

used for inoculation, 353 
Ratio of weight of organs to body, xxiv, 

P- 357 
Ray-fungus, 290 
Raynaud's disease, 254 
Razor, 29 

Reaction, agglutinative, diseases diagnosed 
by, 115 
for diagnosis of human blood, 118 
in blood and other substances, 118 
semen, 417 
amyloid, of kidney, 179 
glycogenic, in blood, 120 
of diabetic blood, 224 
organs, 20 
Receptaculum chyli, 197 
Von Recklinghausen's disease (hsemo- 

chromatosis), 254 

Records, post-mortem, 13, 22, 23, 24, 26, 27 

of findings in lower animals, 394 

necropsy, scheme for, in 

lower animals. 394 

Rectal enema, reversed peristalsis after, 

169 
Rectum, congenital polypi of, 69 

diseases of, 69, 305, 306, 308, 312 
examination of, 15, 69, 166, 442 
fistulse of, 69 
hemorrhoids of, internal and external, 

69 
imperforate, 279 
removal of, 184, 442 

in animals, 377 
prolapse of, 69 
tumors of, 69 
Recurrent fever, see Relapsing fever, 
typhus, see Relapsing fever. 



INDEX 



537 



References, medicolegal, xxix, p. 474 

post-mortem, xxix, p. 465 
Refrigerator box. 10, 11 
Regional landmarks. 17 
Regulations of court, 397 

Prussian, for performance of medico- 
legal postmortems, xxvii, p. 436 
Regurgitation, tricuspid, 133 
Relapsing fever, 302 
Relation between cortex and medulla of 

kidney, 179 
Remedies, internal, toxicology of, 422 
Remittent fever, see Intermittent and Ma- 
larial fever. 
Removal of abdominal contents of ani- 
mals, 378 
dog, 393 
brain, almost intact, 281 

in animals, 388 
cerebellum, medulla oblongata, 

and pons Varolii, 236 
child's brain, 276 
extremities of an animal, 375 
female genitalia. 183 
head of animal from trunk, 386 
hide of an animal, 375 
ileum of animals, 37S 
jejunum of animals, 378 
kidneys of animals, 380 
liver of animals, 380 
male organs of generation, 185 
spinal cord in animals, 389 
sternum, 93 

stomach of animals, 380 
thoracic contents of animals, 384 
vertebral column, 242 
Renal, see Kidney. 
Report, final, of postmortem. 445, 447 

form of, in medicolegal post-mortem 
examinations, 403 
Reptiles in comparative pathology, 374 
Resident physicians. 3. 6 
Resolution of lung. 153 
Respiration, absence of, how determined, 

47 
time of cessation of. 47 
Winslow's test for, 47 
X-rays used to detect any movement 
of,' 47 
Respiratory apparatus, diseases of. ix, p. 

141 : 455- 456 
Responsibility of physician. .16, xvii, p. 397 
Restoration and preservation of body, xx, 

p. 283 
Restricted post-mortem examination-, xix. 

p. 280 
Retina, examination of, 

fixatives for. 339 
Retractors, hooked, 32 
Retroperitoneal glands, examination of, 
14, 196 
tumors of. 196 
Retropharyngeal ab^ce^. 292 



Reversed peristalsis, 169 
Rhabdomyomata of heart, 134 

kidney, 204 
Rhachioschisis, 249 
Rhachiotome, Luer's, 29 
Rhachipagus, 67 
Rhachitic cirrhosis of liver, 217 

rhinitis, 272 
Rhachitis, 71, 72, 272 
Rheumatic arthritis, 263 

fever, 303 
Rheumatism, 12, 303, 351, 451 
Rheumatoid arthritis, 262, 266 
Rhinitis, 141, 142, 272 
Rhinoliths in nasal passages, 141 
Rhinoscleroma, 141 
Rhubarb root, effect on urine, J25 
Rhus toxicodendron, toxicology of, 422 
Ribs, caries of, 81 
cervical, 68 

diseases of, 68, 72, 93, 94, 99, 246, 290 
examination of, 68, 72, 81, 94 
of animals, method of cutting, t>77 
tumors of, 273, 274 
Rice bodies, 261 
Rice-water, 293 
Richardson blue, 345 
Ricin, toxicology of, 434 
Rickets, 71, 72, 272 
" Riders" bones, 83 

Rigidity, post-mortem, or death-stiffen- 
ing, 50, 51, 52, 281 
absent in immature fcetus, 52 
after high mental tension, 51 
ante-natal, 404 
changes in muscle sheaths found 

in, 51 
delayed by rapid cooling of body, 
52 
section of one ischiatic 
nerve, 51 
duration of, 51 
in cachectic subjects, 50 
cholera, 51 

chronic alcoholism, 50 
heat-stroke, 50 
scarlet fever, 304 
spinal poisons. 51 
strychnine poisoning. 50, 51 
suffocation. 50 
suicide, 51 
tetanus, 51 

veratrum viride poisoning, 51 
instantaneous 51 
location of beginning of, 51 
of soldier 1 - on battle-field, 51 
overcome by force, 52 
position of band- in. 51 
post-mortem, 51, 52 
reaction of muscles in, ;j 
time of beginning of 

mpletion of. 51 
Rigor mortis 50. ;i. 52. 281 



.35 



538 

Ripault's test of pupils, 48 
Robin's Injecting fluid, 344 
Rokitansky's 30,000 postmortems, 7 
Rose rash, 331 
Rotheln, 303 
Rough on rats, 429 
Roux's inoculation syringe, 354 
Rubber gloves, 34, 343 
Rubella, 303 
Rubeola, 300 

Rudimentary uterus, 209 
Rue. toxicology of, 424 
Rule for determining weight of cerebrum 
from height of body, 363 
steel, in measuring an organ, 360 
to convert grammes into ounces and 

grains, and vice versa, 357 
two-foot, 32 
Rules for determining lunar months of 

embryo, 358 
Ruminant, nasal and cranial cavities in, 

lines used in sawing, 390 
Ruminants, postmortems on, 389 
Rupia, 307 

Rupture of aneurism, 138 
bladder, 206 

heart, spontaneous, cause of, 129 
tubal pregnancy, as cause of 

death, 460 
uterus, as cause of death, 460 
varicose veins of vulva, 69 
spontaneous, of heart, 129 



Sabina, toxicology of, 424 
Saccular aneurism, 138 
Sacculated aneurism treated by electroly- 
sis, 139 
Saddle-back nose, 68 
Sago spleen, 164 

Salicylic preparations, toxicology of, 422 
Salivary calculi, 260 

glands, diseases of, 66, 259, 294 
examination of, 66, 260, 442 
tumors of, 260 
weight of, 366 
Salivation, drugs producing, 423 
Salpingitis, 208, 297, 314 
Salt water, drowning in, 416 
Sand, false, in intestines, 170 
Sand-flea, 319 
Santonica seeds, 425 
Santonine, toxicology of, 421, 425 
Saponiferous substances, toxicology of, 

425 
Saponine, toxicology of, 423 
Sarcinae, 351 

Sarcoma, as cause of death, 408 
in larynx, 143 

nasal passages, 141 
metastatic. y ? 
nodules of. in omentum. 159 



INDEX 



Sarcoma of bladder, 205 
bone, 274 
brain, 255 
choroid, 75 
ciliary body, 75 
eye, 16 
heart, 134 
intestines, 171 
kidney, 204 
liver, 16, 219 
mediastinum, 146 
periosteum, 274 
pituitary body, 247 
pleura, 156 
spleen, 164 
tonsils, 143 
urethra, 70 
vulva, 69 
spindle-celled, in mediastinum, 146 
of lungs, 156 
Sarcoptes scabiei, 320 
Satchel, contents of, for post-mortem 

work, 35 
Saturnism, toxicology in, 421, 422, 452 
Sausage and fish poisoning, toxicology of, 

422, 423 
Sawdust in preservation of body, 283 
Sawing skull, 226 
Saws, 29 

butcher's meat-saw, 29 
Hey's, for opening skull, 29 
Luer's double rhachiotome, 29 
metacarpal, 29 
Scalds and burns, extent of injuries in, 

412, 463 
Scale, moisture, 114 

post-mortem color, method of using, 

113 
Tallqvist's blood-color scale, 113 
Scales, 10, 32 
Scalp, diseases of, 97, 295 
examination of, 14, 225 
method of replacing, 285 
Scalpel for solids in smear preparations, 

348 
Scalpels, 29 

Scarification on dead subject, 47 
Scarlatina, synonyms of, 448 
Scarlatinal cirrhosis of liver, 217 
Scarlatinous angina, see Scarlatina. 
Scarlet fever, 303, 351 

complications of, 448 

to be distinguished from Duke's 

fourth disease, 300 
virus of, toxicology of, 424 
Scars, 64, 65 

from hypodermics, 65 

in death from electricity. 65 

location of, 65 

of kidneys, 179 

significance of, 64 

surgical, 64, 65 

syphilitic, of penis, 68 



INDEX 



539 



Scheme, author's, for classification of 

poisons, 420 
Schweinfurth-green, toxicology of, 423 
Scilla, toxicology of, 424 
Scirrhous cancer of lungs, 156 

stomach, 190 
Scissors, 31 
Sclera, 75 
Scleroderma, circumscribed, 305 

diffuse, 305 

organism of. 293. 350 
Sclerosis, arterial, 223 

disseminated, 254 

insular. 254 

posterior, see Locomotor ataxia. 
Scoliosis. 198 
Scopolamine, toxicology of. 422. 423. 42.1. 

426 
Scorbutus. 452 
Scrofula, 450 
Scrotum, absence of, 69 

atrophy of. 69 

cleft, 69 

contraction of, 69 

diseases of, 69. 140 

examination of, 69, 73. 444 

hematocele of, 69 

hernia of, 69 

hydrocele of, 69 

hypertrophy of, 69 

'hangitis of. gangrenou>. 69 

tumors of, 69 
Scurvy. 126 

Seat-worms, odor in, 170 
Sea-weed in body, 283 
Sectio cadaveris, see Postmortem. 

anatomica, see Postmortem. 
Section, see Postmortem. 

of oral cavity and cervical organs in 
animals, 384 
Sectioning brain, methods of. 234, 235. 237 

cranium in animals, 386 
Section?, frozen, preparation of, 12 

of organs for preservation, 327 
tumors for preservation, 327 
Sedative alkaloidal poisons, 421 

poisons, 421 
Seeds, santonica, effect on urine. 425 
Segmentation of heart, 129 
Selection of culture-media, 349 

site for inoculation. 355 
Selenium, toxicology of, 426 
Semen. 417 

biologic blood-test for. 417 

Florence te-t for. 417 

precipitin method for, 417 
Semilunar cartilage*-, dislocations of. 266 

ganglia. i8r 
Seminal vesicles, dimensions of. 372 

Naiiwerck's method of finding. 
187 
Senile arterio-clero>i = . 135 

atrophy. 129 



Senile debility, synonyms oi, 402 
Senna leaves, effect on urine, 425 
Septicaemia, puerperal, synonyms of. 400 
Septic plague, 301 

Septum of nose, deviation of, 68. 141 
Serous and mucous membranes, preser- 
vation of. 327, 337 
membrane, appearance of. when dis- 
eased, 85, 97 
when normal, 07 
tuberculosis of, 317 
Serum blood-test, 118 
Setons, scars from. 04 
Sex, 55 

in hermaphrodites. 55 
Shaft, ventilating. 11 
Shape of organs, 16, 18 

skull, 360 
Shavings in preservation of body. 283 
Sheaths. 272 
Sheep, " plaques chorialo" of. 70 

post-mortem examination of, 391 
Shiga, bacillus of, 172 
Shock, death due to. 409 
Shortened mesentery, 160 
Shortening of limb, 56 
Shoulders, circumference of, 56 
Siderosis, 155 

Sigmoid flexure, redundancy of, 20. 160 
Signs of death, 46 

degeneration, 70 
Silicosis, 155 

Silver nitrate solution for post-mortem 
wounds, 43 
Hume's intravenous injection of. 

44 
toxicology of. 411. 422. 423. 434 
Single monsters. 67 

Sinus of Valsalva, aneurisms of. 131. 138 
Sinuses, accessory, exposure of, in ani- 
mals, 389 
longitudinal, 304. 439 
Site of inoculation in animals, 354 
Sitotoxismus, 418 
Size, how estimated, [8 
Skeleton. 58 

peculiarities of female. 58, §9, 
male. ;8, 59 
Skin and its appendages, v. p. 59; 206. 461 
acne of. 63 

angioneurotic cedema of. 64 
atrophy of. 63 
bed -ores of. 63 
blot- of, 63 
bron/imj of. [6, 62 
color <>f. 59, 00. 62, 122 
dirt on, 59. 6l 

diseases of, 44. 53. 60. 62, 63. 64. 65, 

66, [l6, \22, 12.^. 12.;. [26, 128. 132. 

140, 252, 200, 291. 294, 206. 209, 300. 
302. 305. 306, 307, 317. 318, 31 

324. 41 r. .jr-'. 414, j20. \2j. 128. 431. 
433- 438 



540 



INDEX 



Skin, epithelioma of, 63 

examination of, 53, 59, 69, 6t, 62, 63, 

04. 65, 00, 405 
fixatives for, 340 
in actinomycosis, 63 

Addison's disease, 60 
albinism, 00 
anaemia, 62 

anthrax. 63 

arsenical poisoning, 63 

blastomycosis, 6} 

Bright's disease, 64 

chimney-sweeper's cancer, 63 

chloasma, 62 

chlorosis, 60, 122 

cholera Asiatica, 293 

dermatitis herpetiformis, 63 

dermatomyositis, 63 

diabetes, 64 

drowning, 66 

ecthyma, 63 

eczema, 63 

ergotism, 64 

erythema multiforme, 62, 63 

furunculosis, 63 

gangrenous lymphangitis, 64 . 

herpes, 62 

ichthyosis, 63 

impetigo, 63 

keloid, 64 

keratosis. 63 

leprosy, 60, 63 

lichen, 63 

locomotor ataxia. 63. 64 

lupus vulgaris, 63 

measles, 62, 63 

mercury poisoning, 62 

miliaria, 63 

moles, 62 

myxcedema, 63 

naevus pigmentosa. 62 

pediculosis. 62 

peliosis rheumatica, 62 

pemphigus, 63 

pernicious anaemia, 60, 63 

pityriasis, 62, 63 

planus, 63 

prurigo, 63 

psoriasis, 63 

puerperal fever. 64 

purpura, 62. 63 

rheumatism. 62 

ringworm, 63 

scabies, 63 

scarlet fever, 63 

scleroderma, 63 

scrofulosis, 63 

scurvy, 64 

seborrhoea, 63 

smallpox. 62. 63 

snake poisoning, 62 

syphilis, 62. 63 

tinea sycosis, 63 



Skin in tuberculosis, 318 
typhoid fever, 318 
typhus fever, 62 
uraemia, 64 
varicella, 63 
vitiligo, 60 
xanthoma, 64 

parchment-like spots of, 65 

tumors of, 62, 63, 64, 66 

ulcers of, 63 

vesicles of, 62, 63 
Skull, altitudinal index of, 360 

base of, examination of, 233 

brachycephalic type of, 361 

cephalonic type of, 361 

characteristic measurements of, 360 

clamp, 32 

clinocephalic type of, 361 

diseases of, 72, 226, 247, 251 

dolichocephalic type of, 361 
. examination of, 14, 58, 72, xiii, p. 255 

fracture of, 1, 408, 411 

French method of opening, 228 

hydrocephalic type of, 361 

measurements of, 229, 361 

methods of restoring and preserving, 
283, 284 

microcephalic type of, 361 

opening of, with a hammer, 228 

orthocephalic type of, 361 

orthognathous, 361 

oxycephalic type of, 361 

pachycephalic type of, 361 

pathologic types of, 361 

plagiocephalic type of, 361 

platycephalic type of, 361 

prognathous type of, 361 

rhachitic shape of, 72 

sawing of, 226 

shape of, 360 

sphenocephaly type of, 361 

sutures in restoring, 283 

thickness of, 229 

trigonocephalic type of, 361 

trochocephalic type of, 361 

tumors of, 273, 274 

weights of contents of, 360 
Skullcap, see Calvarium, 230 
Sleeping sickness, 324 
Sloughing, as a complication of typhoid 

fever, 448 
Small intestine, see Intestine, small. 
Smallpox, 16, 48, 64, 305, 351, 448 

bronchopneumonia, as a complication 
of, 306 

cause of sudden death, 16 

complications of, 448 

hemorrhagic, 305 

odor of, 305 
Smear culture, 352 

preparations, 247 
fixing of, 348 
Smell, sense of, development of, 21 



INDEX 



541 



Smokeless powder., indistinct markings 

made by, 409 
Smoking, prohibition of, at postmortem, 6 
Snake venom, toxicology of, 434 
Soapstone, ground, for preserving rubber 

gloves, 34 
Society, American Anthropometric. 4 
Sodium chlorid and bichlorid of mercury 
solution. 334 
nitrite, toxicology of, 423, 425 
thiosulphate of, toxicology of. 424 
urate, 207 
Soft chancre. 450 
Solanine, effect on urine, 425 
Solanus pseudocapsicum, toxicology of, 

419 
Soldiers, post-mortem rigidity in, 51 
Solid material, method of removing from 

interior of an organ, 347 
Solids in smear preparations, 348 
Soluble cells, preservation of, 328 
Solution, bichlorid-tablet, in preservation 

of tissues. 326 
Sore, syphilitic, 349 
Spanish fly, toxicology of, 422 
Spasms, as a complication of whooping- 
cough, 448 
Spatula, spear-headed, 347, 348 
Specific gravity of bile, 214 
blood, 114 
brain, 363 
kidney, 368 
liver, 367 
lung, 366 
pancreas, 369 
Specimens, general method of preserving, 

343 
injected, 344 

Kaiserling's method of preserving, 343 
Littlejohn's method of preserving. 345 
macroscopical. examination of, 341 
microscopic examination of, xxii, p. 

326 
natural color of, method of pre- 
serving. 344 
of peritoneal fluid from inoculated 
animals, 356 
urine from inoculated animals, 

356 
various tissues from inoculated 
animals. 356 
preservation of. xxii. p. 326 
removed at autopsies, 6 
washing of, 342 
Spectroscopic examination of blood, 113, 

418. 444 
Spermatic cord, diseases of. 212 

examination of. 14. 186. 212 
duct. 14 
Spermatozoa. 46. 417 
Sphenocephaly skull, 361 
Spina bifida. 68. 2"" 
Spinal arthritic 2^4 



Spinal canal, method of examination of, 
xiv, p. 242 
column in postmortem, 440 
cord, appearance of, in anthrax, 440 
atrophy of, 253, 254 
diseases of, 68, 82, 122, 205, xv, 
p. 246; 291, 297, 307, 308, 310, 
313, 404, 413, 430, 433 
examination of, 14, 243, 440 
hemorrhage of, 251 
in postmortem, 440 
.measurements of, 364 
method of removing from body of 

baby, 277 
miliary tuberculosis of, 313 
opening of, 244 
preservation of, 244 
other diseases of, 452 
removal of, 7, 14, 242, 243, 244, 
254, 274, 277, 440 
from back, 242 
front, 245 
in animals, 380, 389, 394 
study of, for removal, 243 
tuberculosis of, 252, 313 
tumors of, 255 

weight and dimensions of. 364 
curvatures, 269 
ganglia, 243 

membranes, hemorrhage of, 251 
nerves, 243 
Spindle-celled sarcoma in mediastinum, 
146 
of lungs, 156 
Spiral douche, use of, to produce abortion, 

406 
Spirals, Curschmann's, 144 
Spirochsetse of Obermeier, 302, 351 • 
Spleen, 162 

absence of, 162 

amyloid degeneration of, 164, 307 
anaemic infarcts in, 163 
angiomata of, 164 
cancer of, 164 

changes in, in scarlet fever. 304 
coal-dust in, 163 
dimensions of, 369 

diseases of, 18, 66, 85, 117, 123, 124, 
125, 127, 132, 144, 153, 161, 162, 163, 
164, 181, 100, 217, 228, 291. 295. 299, 
302. 305. 307, 308, 317, 323, 428, 431, 
458 
echinococci cysts in, 164 
elastic tissue of, 163 
embolic infarct of, 163 
enlargements of, 62, 163, 305 
examination of, 14, 15, 762, 163, 442 
fixatives for, 340 
hyperaemia of. 163 
leukemic, 164 
measurements of, 162, 369 
method of removing. 162 
normal color of. T63 



542 



INDEX 



Spleen, oi animals, removal of, 379, 380 
inoculated animals, securing ma- 
terial From, 356 
oligemia of, 163 

Pentastomum denticulatum of, 164 
remo\ al of, 15. H>-\ 2S0 

in animals, 356, 379- 381, 382 

rupture of, 303 

sago, [64 
sarcoma of, 104 
tuberculosis of, 104, 311 
tumors oi, 116, 164 

volume of, 369 

weight of, 162. 360, 369 
Splenitis, acme, 1O3 
Spondylitis deformans, 263 
Sponges, 33 

Spontaneous rupture of heart, 129 
Spores, bacterial, longevity of, 356 
Spots, Tardieu's, 130 
Sprains, synonyms of, 463 
Sprue, 306 

Spurious aneurism, 137 
Stab cultures, 352 
Stain, trypan red, 325 
Stains, iodin, removal of, by ammonia, 286 

on clothing, 54, 117 

location of, to be marked, 54 
Staphylococci, 151 

immunity to, 43 
Staphylococcus aureus, 160, 351 
Starvation, death by, indications of, 41A 
Statistics, constant revision of, 3 

morbidity and mortuary, xxviii, p. 448 
Stature, abnormalities of, 56 
Status lymphaticus, 279 
Steel tape measure, 32 
Stegomyia, in yellow fever, 319 
Stenosis, 145 

aortic, 133 

laryngeal, 143 

mitral, 133 

of bronchi, 126 

pulmonary valves, 133 
trachea, 146 
ureters, 204 
uterus, 209 

pyloric, 190 
Sterility in dwarfism, 56 
Sterilizing instruments, 28, 45, 352 

syringes, 354 
Sternum, absence of, 68 

and ribs, altered shape of, 94 
examination of, 94 

congenital luxation of, 266 

diseases of, 68. 71, 72, 94, 246, 265, 266, 
290 

ensiform appendix of, 94 

examination of. 68. 71. 94 

<-ro~ion of. 94 
:re of. 68 

fracture of, location of, 94 

in carcinoma of breast. 94 



Sternum, marrow of, changes in, 94 
pressure atrophy of, 94 
regulations tor removal of, 93 
removal of, 93 
restoration of, 285 
tuberculous caries of, 94 
tumors of, 274 
Stillbirths, 464 
Stillborn babes, hemorrhage in, 95 

thymus gland of, 95 
Stomach and duodenum, of animals, re- 
moval of, 379 
oesophagus, method of examining, 
188 
cancer of, 190 

cancerous, removal of, during life, 190 
capacity of, estimation of, 90 
colloid cancer of, 190 
contents of, examination of, 189 

in peritoneal cavity, 87 
dilatation of, 190 
dimensions and weight of, ^ 
diseases of, 88, 90, 122, 151, 153, 190, 
191, 192, 217, 220, 224, 297, 299, 302, 
318, 319, 419, 426, 427, 428, 430, 431, 
432, 433, 444 
examination of, 14, 15, 90, 188, 189, 

190, 191, 192, 442, 443, 444 
exenteration of, in animals, 381 
gas in, post-mortem, 90 
hemorrhage from, 192 

petechial, from, 192 
hour-glass contracture of, 90, 191 
in animals, examination of, 383 
in postmortem, 443 
measurements of, 366 
mucous membrane of, action of poi- 
sons on, 419 
medullary cancer of, 190 
of animals, removal of, 380 
position of, in babe, 90 
relative position to umbilicus, 17 
removal of, 15, 188, 189, 443 

in animals, 379, 381, 382, 391, 

393 
scirrhous cancer of, 190 
serous covering of, examination of, 89 
size and situation of, 90 
tuberculosis of, 312 
tumors of, 90, 122, 190 
ulcer of, synonyms of, 457 

with perforation, 87 
unusual articles found in, 189 
weight of, 360 
Stomach-pump, S3 
Stomatitis aphthosa epizootica, 295 
Stone formations in kidney, 204 

urine, 204 
Stools, appearance of, in cholera Asiatica, 

293 
Strabismus, 73, 74 

Stramonium, toxicology of, 411. 414, 418. 
422 



INDEX 



543 



Strangulation, 415 
Streptococci, 151 

immunity to, 43 
Streptococcus, 295 

intracellulars, 351 

lanceolatus, 160, 351 

pyogenes. 160, 351 
Streptothrix actinomycosis, 290, 351 
Stricture of oesophagus, 190 

syphilitic, of bowel, 306 

urethral, location of. in male, 70 
Stroke culture, 352 
Strongylus, 151 

annatus, 138 

gigas, 202 
Strophanthus, toxicology of, 424 
Strychnine, toxicology of. 41 1. 419, 421, 
4^6. 435 

effect on urine, 426 

poisoning, post-mortem rigidity in, 51 

test for. in urine, 435 

toxicology of. 421, 426, 435 
Struma aneurysmatica. 147 

varicosa, 147 
Subacute bronchitis, 144 
Subcutaneous hemorrhages in plague. 302 

inoculation of animals, 354 
Subdiaphragmatic abscesses. 159 
Sublamin, 335 
Sublingual glands, 15, 366 
Submaxillary glands, 80, 366 
Submersion, accidental 463 
Subphrenic abscesses, 159 
Sudden death, causes of, 407, 464 

due to pressure of thymus. 96, 279 
Suffocation, 415 

death by, delays loss of vital warmth. 

49 
possible findings in, 415 
post-mortem lividity in, 50 
Suggestions, medicolegal, xxvi. p. 397 
Suicide, 409 

by asphyxia. 462 
crushing. 463 
cutting instruments. 462 
drowning, 462 
firearms, 462 
hanging, 462 

jumping from high places, 463 
poison, 462 
strangulation, 462 
ingenious ways of. 410 
methods of committing, 410 
number of. increasing. 409 
order of frequency of, 410 
Sulohide of antimony, toxicology of. 418 
Sulphonal, toxicology of, 421, 425 
Sulphuric acid, toxicology of. 426 
Sulphurous acid, toxicology of, 422 
Sunstroke. 4T4 
blood in. 414 

lividity and putrefactive change^ in. 
4T4 



Sunstroke, temperature in, 414 

venous engorgement in, 414 
Supernumerary fingers and toes, 68 

see Accessory under organs. 
Suppuration complicating smallpox, 448 

due to tuberculous lesions, 311 

of lung, 153 
pleura, 156 
Suppurative appendicitis, 171 

bronchitis, 145 

cholangitis, 219 

exudates, odor, etc., of, 86 

gastritis, 191 

hepatitis, 219 

periostitis, 271 
Suprarenals, see Adrenals. 
Surgery, practice of, at postmortems, 3 
Surgical instruments in abdominal cavity. 

88 
Surra. 324 

Surroundings, study of, 54 
Suspended animation, cases of, 46 
Sutures in restoring skull, 283 
Suturing of heart muscle, 100 
Sweating (miliary) fever, 449 
Swine, postmortems on, 391 
Symelus, 67 

Sympathetics, 14, 16, 97, 276 
Symptoms observed after the administra- 
tion of the more common poisons, 421 
Syncephalus, 67 
Syncope, fatal, 21 
Syncytioma malignum, 209 
Syndesmosis, 266 
Synonyms of causes of death, xxviii, p. 

448 
Synostosis, 266, 269 

premature, 361 
Synovial membrane, 261 
Synovitis, catarrhal, 262 
Synthetical organic poisons. 421 
Syphilis. 351, 450 

acquired, 306 

as a cause of spontaneous abortion, 
406 

chancre of, 307 

choroiditis due to, 307 

congenital, 307 

as cause of death, 408 

cutaneous eruptions in, 307 

finger-nails in, 307 

germs of, 296 

gumma of, 306 

hepatic cirrhosis due to, 216 

hereditary. 277. 306 

initial legion of. 306 

iritis due to. 306 

mucous patch of, 306 

of arteries, 137 

brain. 255. 308 

circulatory system, 307. 308 
rord, 308 
gastro-intestinal tract, 308 



544 
Syphilis 



INDEX 



of heart, 133 
kidneys, 308 

larynx, 300 
liver, 309 
lung, 309 

lymph-vessels, 140 
nervous system, 307 
skin, 306. 307 
testes, 310 
\ ulva, 69 

parotitis duo to. 306 
periostitis due to, 306 
tertiary stage of, 307 
ulcerating lesions of, 63 

Syphilitic arthritis. 264 
bone lesions, 72 

cirrhosis of liver, 217 

congenital, pancreatitis, 221 

hydrocele, 417 

inflammation of veins. 140 

pancreatitis, 221 

periarteritis of pancreas, 222 

sore, 349 

ulcers of oesophagus, 190 
vagina, 211 
Syringe, hypodermic, in inoculation of 
animals. 353 

Koch's inoculation, 353 

method of holding in intravenous in- 
oculation of animals, 355 
Syringes, sterilizing of, 354 

used in inoculation of animals. 353, 

354 
careful treatment 
of. 354 
Syringomyelia. 255. 264 



Tabes, dislocations common in, 262 
dorsalis, 248, 306 
mesenterica, 160 

Table, dimensions of postmortem. 11 

of approximate weight of internal or- 
gans, 360 
changes in urine effected by poi- 
SOns and medicines. 424 
portable post-mortem, g 
showing difference between crounous 
and catarrhal pneumo- 
nia, 154 
tuberculous and typhoid 
ulcers, 167 
in grammes the mean weights of 
the brain, 362 
Table-, construction of, 33 

ights and measures, 17 
rota tine. 33 
wriediing. t,t, 

zinc-covered, wood, -late, iron, or 
glass, 33 
Taenia, bothriocephalus latus, T2T. 320 



Taenia rlavopunctata, 320 

mediocanellatse, 170 

nana, 170 

saginata, 320 

solium, 320 
Talipes calcaneus, 269 

cavus, 269 

equinus, 248, 269 

planus, 269 

valgus, 269 

varus, 269 
Tallqvist's blood-color scale, use of, 113 
Tannin, toxicology of, 435 
Tardieu's spots, 101, 130 
Tar, toxicology of, 422 
" Tea" cigarettes, poisoning therefrom, 412 
Technic of exposing thoracic cavity, vii, 

P- 92 

opening abdominal cavity, vi, p. 

79 
postmortem, 437 
Teeth, 78 

actinomycosis of, 290 

anomalies of, 78 

condition of, 78 

deformities of, 257 

diseases of, 78, 140, 251, 290, 308 

examination of, 53, 78, 438 

in pernicious anaemia, 121 

special authority for removal of, in 

France, 6 
syphilitic, 78, 308 
tumors of, 78 
Tellurium, toxicology of, 21, 424, 426 
Temperature at which pathogenic bacteria 
grow best, 352 
in cases of certain abdominal disor- 
ders, 49 
cholera, 49 
injury to nervous system, 

49 
sunstroke, 414 

of animals, how taken, 353 

rectal, after death, 49 

rise of, after death, 49 
Tenaculum, 32 
Tendons, 14, 272 
Tenosynovitis, acute, 272 

chronic, 272 

haematogenous, 272 

simple, 272 

tuberculous, 272 
Terata anadidyma, 67 

anakatadidyma, 67 

katadidyma, 67 
Teratoma of pleura, 156 
Tertian malaria, 322 
Tertiary stage of syphilis, 307 
Test, antiserum, 118 

Gmelin's, for bile, 120 

Widal, for distinguishing human 
blood, 120 
Testes, see Testicles. 



INDEX 



545 



Testicles, abnormal position of, 69 

abscess of, 211 

absence of one or both, 68 

atrophy of, 69, 211, 419 

dimensions of, 370 

diseases of, 68, 211, 300, 301, 307, 310, 
313, 324, 419 

duplication of, 69 

ectopia of, 69 

examination of, 14, 15, 68, 73, 186, 
44^ 444 

external method of examining, 186 

hypertrophy of, 69 

hypoplasia of, 69 

inflammation of, 211 

injury of, 211 

malformation of, 69 

measurements of, 370 

removal of, 185, 186 

swelling of, 69 

syphilis of. 211, 307, 310, 314 

true abscesses in, 211 

tuberculosis of, 211, 314 

tumors of, 211 

undescended, 69 

weight of, 360, 370 
Testimony, expert, 398, 399 

in court. 17 

medicolegal cases, 400 

of a medical man in medicolegal cases, 
400 
Tetanus. 40. 310 

antitoxin, its subdural use, 45 

neonatorum, 310 

post-mortem rigidity in. 51 

precautions when feared. 45 

synonyms of, 453 

toxin of, toxicology of, 421 
Tetranol. toxicology of, 425 
Thawing of frozen bodies. 289 
Thermocautery. 35 
Thionin. 341 
Thioulphate of sodium, effect on urine, 

424 • • , • • 

Thoracic cavity, critical examination of, 

vii. p. 92 : 440 

contents in animals, removal of, 384, 

393 
of animals, exposure of, 376 
duct. 14. 15. 37- 197- 198, 365 
organs, ablation of. 382 

in animaK dissection of. 384 

technic of exposing, vii. p. 92 

Thorax, appearance of. in anthrax. 291 

emphysema of lungs, 149 
method of injecting embalming fluid 
into. 288 
opening. 92 
Thread, to remove food from teeth, may 

poi-on. 412 
Thrombi in chlorous. 123 
of heart. T37 
tuberculo'- 



Thrombo-arteritis, 136 
Thrombosis, 20, 136 

and embolism, synonyms of, 455 
as cause of death, 408 
of brain, 250 
dura, 233 
portal vein, 195 
pulmonary vein, 148 
superior mesenteric artery, 137 
veins, 139 
Throttling and hanging, differentiation of,. 

415, 416 
Thrush, 192, 209, 310 
Thuja, toxicology of, 424 
Thymol, effect on urine, 425 
Thymus gland, abscess of, 95, 96 
color of, 95 
dimensions of, 370 
diseases of, 70, 95, 123, 147, 181* 

246 
enlargement of, causing asphyxia, 

279 
examination of, 15, 95, 441 
loses coloring matter when 

washed, 19 
hemorrhage into, 95 
in acromegaly, 95 
adult, 95 
certain pathologic conditions, 

95 
exophthalmic goitre, 95 
myxcedema, 95 
removal of, 15, 445 
tumors of, 95, 96, 246 
weight of, 95, 370 
Thyroid gland, accessory, 96 

anatomic changes in, 249 

arsenic in, 249 

atrophy of, in dwarfism, 36 

degenerations of, 96 

dimensions of, 370 

diseases of, 56, 66, 70, 73, 96, 123, 

146, 222, 246, 249, 455 
enlarged, 66, 96 
examination of, 15, 66, 96, 442 
fixatives for, 341 
hypertrophy of, 96 
measurements of, 370 
myxcedematous degeneration of, 

96 
pyramid of, 96 
removal of. 15, no 
symptoms following removal of, 

96 
tumors of. 96. T46. 147, 246 
weight of. 370 
Thyroiditis in diphtheria. 96 
Time after death before making an au- 
topsy, 50 
for body to skeletonize, 59 

weighing or^an^. 3^7 
of complete post-mortem cooling, 49 
T-incision, 259 



540 



INDEX 



rinea favus, 401 

tonsurans, trichophyton, 401 
Tissues, for preservation, permission to 
remove, 5 

preservation of, xxii, p. 326 . 
Toadstool, 434 

Toluidin, toxicology of, 423 
Toluylendiamin, effect on urine, 425 
Tongue, atrophied (microglossus), 68 

cleft, 68 

deformities of, 68 

diseases of, 67, 68, in, 128, 140, 302. 
310, 312 

examination of, 15, 96, III, 438, 442 

t'raimm of, too short or too long, 68 

hypertrophy of, 68 

maeroglossus of, 68 

oesophagus, trachea, and adjacent 
structures together, removal of, no 

removal of, 15, 37, 96, 110, 280, 442 

tuberculosis of, 312 

tumors of. III, 140 
Tonsils, angioma of, 143 

diseases of, 124, 143, 294, 304, 307, 312 

epithelioma of, 143 

examination of, 15, III, 442 

fibroma of, 143 

hypertrophied, 143 

lymphoma of, 143 

myoma of, 143 

papilloma of, 143 

removal of. III 

sarcoma of, 143 

tumors of, 143 
Tophi, 72, 128 

murexoid test for, 73 
Topographic examination of abdominal 

cavity, vi, p. 79 
Tow, for packing large cavities, 34 
Toxic angina, see Diphtheria and Croup. 

arthritis, 264 

gastritis, 192 

inanition, 418 

purpura, 126 
Toxicology, xx vi, p. 417 and the various 
drugs themselves. 

definition of, Robert's tables on, 421 
Toxin of tetanus, 421 

increases constitutional symptoms, 43 
Trachea, calcareous and papillomatous ex- 
crescences of, 146 

es of, 97, 112, 144, 297 

examination of, 14, 96, 1 12, 442, 445 

fistula in. 144 

in animaN. dissection of, 385 

injuries of. 112 

removal of. o/>. 1 10. 444 

stenr>-i~ of, 1 \ ( > 

tongue, resophagus, arid adjacent 
Structures together, removal of, no 
Trachoma, contagious granular lids, 4=4 
Tract, genito-urinary, xi, p. 199 

intestinal, gall-stones in, 170 



Tract, intestinal, worms in, 170 

respiratory, diseases of, 141 
Traction aneurism, 138 
Trade or occupation intoxications, 452 
Trance, cases of, 46 
Transudate, 20 

how distinguished from exudate, 86 
Transverse colon, malpositions of, 90 
Traumatic aneurism, 138 
Traumatisms, 129, 155, 202, 218, 246, 463 
Trays, enamelled, 33 
Treatment of post-mortem wounds, iv, p. 

38 . . 
Trephining engines, 29 
Trichina spiralis, 83, 321, 373, 449 
in tongue of cat, 344 
usual location of, in muscles, 83 
Trichosis vesicae, 206 

Tricuspid orifice of the heart, dimensions 
of, 365 
. regurgitation, 133 
Trigonocephalic skull, 361 
Trional, toxicology of, 425 
Triple monsters, 67 

staining, 341 
Trocar, 32, 65 

curved, method of injecting thorax by 

means of, 288 
use of, in injecting brain cavity, 288 
Tropacocaine, toxicology of, 426 
Trophocephalic skull, 361 
Tropical diseases, Manson's work on, 296 

hepatitis, 219 
True aneurism, 137 
Trypanosoma, 121, 324, 373, 423 
Trypan red, 325 
Tsetse flies, 324 

Tubal pregnancy, see Extra-uterine preg- 
nancy. 
Tubercle, bacterium, 310, 349 

rabic, 298 
Tuberculin, use of, in anatomic wart, 45 
Tuberculosis, 310 
abdominal, 450 
aneurismal arteries in, 316 
as cause of death, 408 
bovine, 373 
calcification in, 312 
caseous, 311 

nodules as lesions in, 316 
cavities as lesions in, 316 
cutaneous forms of, 318 
diffuse, 311, 315 
distribution of, in body, 311 
enlarged bronchial glands as lesions 

in, 316 
general, caused by anatomical wart, 44 
generalized, 450 
human, 373 

as differing from bovine, discus- 
sion of, 373 
hypertrophy of heart in, 316 
lesions of, 311 



1XDEX 



Tuberculosis, lymphatic glands in, 316 
miliary, 16, 311. 313, 315, 317 

distribution of, in body, 311 

of adrenals, 180 

brain and cord, 313 
omentum, 159 
pericardium, oq 
peritoneum, 317 
ureter, 182 
modes oi invasion of, 311 
nasal. 141 
of alimentary tract, 312 

arteries, 137 

bladder, 205, 314 

bone, 72 

brain and cord, 313 

circulatory system, 314 

genito-urinary system, 314 

heart, 134 

intestines, 312 

kidneys. 314 

larynx. 315, 449 

liver, 313 

lung. 315. 449 

lymph-vessels, 140 

mammary gland, 317 

meninges. 450 

mouth, 83, 312 

oesophagus, 190, 312 

peritoneum, 317 

serous membranes, 317 

skin. 318 

stomach. 312 

testes. 314 

thoracic duct. 198 

ureters, 314 

urethra. 70 

vein, 140 
pneumonic areas as lesions in, 316 
thickening of pleura, as lesion in, 316 
ulcerative, 315 

of peritoneum, 317 
Tuberculous affections, 450 
arthritis 264. 265 
bronchitis, 145 
coxalgia, 72 
endometritis. 210 
hydrocele. 417 
knee-joint, 72 
legions, fate of, 311 
periostitis. 271 
spinal curvature. 72 
tumors of brain. 313 
ulcerations. 311 
ulcers. 167 

distinguished from typhoid, 168 
Tubes, infectious material used in. 352 
inoculated, cultivation of, 352 
inoculation of. 352 
Turn' - • of death. 408 

deformity, 72 
cells of. in blood. T20 
I, 78 



547 

Tumors, erectile, of arteries, 137 

lor the different forms of tumors, see 

the organs or parts themselves, 
lymph, 140 
of adrenals, 180 
appendix, 172 
arteries, 137 
bladder, 205, 206 
bone, 273 
brain, 255, 313 
breast, 81 
bronchi, 146 
cord, 255 
dura, 230 
eye, 75 

Fallopian tubes, 208 
gall-bladder, 195 
heart, 134 
intestines, 171 
kidney, 179, 204 
larynx, 143 
liver, 214, 219 
lungs, 155 
muscles, 84 
nasal passages, 141 
ovary, 209 
pancreas, 196 
peritoneum, 159 
salivary glands, 260 
skin, 64 
spleen, 164 
stomach, 190 
testicles, 211 
uterus, 209 
vagina, 211 
veins, 140 
retrobulbar, 258 

sections of, for preservation, 327 
Turmeric paper, 34 

Turpentine as a cause of amyloid degen- 
eration, 418 
toxicology of, 418, 424 
Twine, 33 

Twin pregnancy, history of, 279 
Types of skull due to premature synosto- 
sis, 361 
Typhoid bacilli, 169, 205, 350 
fever, 318 

as cause of death, 408 
complications of, 448 
intestinal lesions of. 318 
mesenteric lymphatic glands in. 

8o, 318 
post-mortem rigidity ' n - 51 
synonyms of. 448 
ulcers. 165, 167 

cause of artificial ami 

congestion in. 89 

how distinguished from tubercu 

Ions ulcers, [68 
in Meckel's diverticulum, » 
of o- tophagus, roo 
Typhus fever, 351 



548 



INDEX 



Ulceration of larynx, 143 

Ulcerations, tuberculous, 311 

Ulcerative colitis, 175 

endocarditis, 132 

phthisis, 311, 315 

tuberculosis, 315 

of peritoneum, 317 
Ulcers, diphtheritic, of vulva. 69 
duodenal. [64 
gastric, situation of, 189 
intestinal, 167 
1 if oesophagus, 190 

stomach, 169, 457 
peptic, 169 

of oesophagus, 190 
perforating, of foot, 248 
syphilitic, of oesophagus, 190 

of vagina, 211 
tuberculous. 167 

of oesophagus, 190 
typhoid, 167 

and tuberculous, table showing 

differences between, 167 
causing artificial anus, 20 
in Meckel's diverticulum, 20 
of oesophagus, 190 
Umbilical cord, 128, 359, 405, 406, 444 
hemorrhage of, 128 
length of, 359 
Umbilicus, 66, 68, 219. 276, 310 
Uncinariasis, 321 

Undertakers, duties of, at postmortem, 9 
Ungentum Crede as local antiseptic, 43 
Unna's alkaline methylene blue, 341 

orcein stain, 341 
Urachus, allantoic cysts of, at navel, 66 

persistence of, 68 
Uraemia, 64. T17, 422 

a- cause of death, 407 
blood changes in, 117 
Uranium, salts of, toxicology of, 425 
ammonium. 207 
lium, 207 
rs, accidental tying of, 182 
cysts of, 204 
dimensions of. 368 

1". 127, 182. 200, 204, 224, 314 
examination of. 14. 15, 175, 176, 181 
miliary tubercles in. T82 
parasites in, 205 
polyps of, 204 

removal of, 176, 184 

in animals, 381 
situation of, 175 

•i- of. 204 

tumors of. t8i. 209 
Urethra, abnormal openings of, 69 
-re of, 60j 
angioma of. 70 

atresia or partial phimosis of, 69 
caruncle of. 70 



Urethra, cleft, 69 

condyloma of, 70 

deformity of, 69 

dimensions of, 368 

discharge from, 69 

diseases of, 69, 205, 297, 459 

epithelioma of, 70 

examination of, 14, 15, 39, 89, 184, 
209, 442 

fibroma of, 70 

inflammation of, 69 

measurements of, 368 

occlusion of, 69 

removal of, 185, 186 

sarcoma of, 70 

stricture of, location of, in male, 70 

tuberculosis of, 70 

tumors of, 69 
Urethritis, 69 
Uric acid, 207 

in blood, in gout, 128 
infarct of kidney, 201 
Urinary salts, precipitates of, mistaken 
for pus, 178 

tract, calculi of, 459 
lesions in, 182 
Urine, black, causes of, 206 

frog test for strychnine in, 183 

of new-born, study of, 278 

specimen of, from inoculated animals, 
356 

stone formation in, 207 

typhoid bacilli in, 205 
Urinometer, 33 
Urobilin, 214 
Urobilinogen, 214 
Uropygium, 394 
Urtica, toxicology of, 422 
Usual causes of death, xxviii, p. 448 
Utensils in postmortems on large domes- 
tic animals, 374 
Uterine hemorrhage, non-puerperal, syno- 
nyms of, 459 

tumors, 209 
Uterus, atresia of, 209 

atrophy of, 209 

bilocularis, 209 

bicornis, 209 
duplex, 209 

bipartitus, 209 

congenital abnormalities of, 209 

cordiformis, 209 

dermoid cysts of, 209 

didelphys, 209 

dimensions of, 371 

diseases of, 128, 201, 209, 210, 407 

displacements of, 209 

double. 209 

examination of, 14, 15, 69, 186, 442 

foreign bodies in, 210 

hemorrhages of, 209 

hypertrophy of, 209 

hypoplasia of, 209 



INDEX 



549 



Uterus, infantile. 209 
infarcts of, 209 
measurements of, 371 
moles of, 209 
other diseases of, 459 
polyps of, 209 
removal of, in animals, 386 
rudimentary. 209 
rupture of, 200 
septus duplex, 209 
situation of. 209 
stenosis of, 209 
sub septus. 209 
thrush fungi in. 209 
tuberculosis of. 209 
tumors of, 209 
unicollis, 209 
unicornis. 209 
weight of, 371 

twenty-four hours after de- 
liverv. 210 



Vagina, abscess of. 211 

diseases of. 210, 211, 297 

erosions of, 211 

examination of, 15, 39. 210. 442 

hematocele of, 211 

hernia of, 211 

poisons in, 211 

prolapse of, 211 

removal of, 183 

in animals, 386 
syphilitic ulcers of, 211 
tumors of, 211 
vegetations of. 211 
Vaginal hysterectomy, 281 
Vaginitis, gonorrhceal. 297 
Valsalva, sinus of, aneurism of, 138 
Valves, diseases of, 130, 132, 133, 142, 153, 
201. 210. 218. 247. 291. 297. 301, 303. 
308, 408 
examination of, 103 

in animals, 385 
measurements of, 103 
mitral and pnlmonarv. situation of, 
"107 
how remembered. 
107 
Vapor fixation. 336 

Vapors of nitric acid. etc.. inhaled, toxi- 
cology of. 423 
Varicella (chicken-pox 1. 
Varicocele, 140 

Varicose veins of vulva, rupture of, 69 
Variola, see Smallpox. 
Varioloid, see Smallpox. 
Va-a deferentia. 224 

Vascular gland-, change- in. in acrome- 
galy. -6 
nephritis, 199 

tem in alcoholism, 427 



Vegetable acids, toxicology of, 426 
irritant poisons, 421 
toxinic poisons, 421 
Vegetations, vaginal hypertrophic, 211 
Veins, azygos, 15 

diseases of, 136, 137, viii, p. 139; 219, 

224. 416. 455 
examination oi, 440 
fibrous endophlebitis in. 140 
hemorrhoids of, 140 
phlebitis of, 139 
phlebosclerosis of, 140 
primary tumors in, 140 
syphilitic inflammation of, 140 
thrombosis of, 139 
tuberculosis of, 140 
tumors of, 140 
varicocele of, 140 
Velum palati, 15, 96, 257, 442 
Vena cava, 14, 15, 101, 156, 197, 365, 442 

in animals, 381 
Venereal warts of vulva, 69 
Venous engorgement in sunstroke, 414 

naevus, 137 
Ventilating shaft, 11 

Ventricles of brain, examination of, 439 
heart, examination of, 102, 441 
thickness of, 105, 106 
Veratrine, toxicology of, 419, 421 
Veratrum viride, post-mortem rigidity in 

poisoning by, 51 
Vermiform appendix, dimensions of, 366 
in hernia, 20 
situation of, 20 
weight of, 366 
Vertebral column, 67, 72, 198, 248, 253, 
254, 255, 265, 290, 303, 311, 402, 440, 442 
Vertical transverse incision of brain, 239 
Vesical calculi, 206 
Vesicles, seminal, 15, 372, 442 
Vesicular emphysema of lungs, 150 
Veterinary postmortems, S73 
Viability of child, how determined, 403 
Vibrio cholera?, 351 

Vienna method of exenteration of ani- 
mals, 382 
Violence as a cause of death. 403, 407, 408 

external, forms of, 408, 463 
Violent death, 408 

Virchow's method of determining bulk, 18 
examining heart, 101 
sectioning brain, 235 
Virus of scarlet fever, effect on urine, 424 
Vise, t> 2 

Vital warmth, In-- of, 48, 49 
Vocal cord-. 73. [II, 142, 256. 309 
Volume of brain. 363 
heart, 365 
liver, 367 
spleen, 369 
Volvulus, 90. 139 

Vomit, suspicious undissolved foreign 
bodies in, 418 



55° 

Vulva, absence of, 69 
acne of, 69 
aphthae of, 69 
atrophy ox, 69 
carcinoma 01, 69 
chancre of, 69 

chancroid, 69 

chondroma of, 69 
diphtheritic nicer- of, 6g 
diseases of, 69, 70 

ma of, 69 
elephantiasis of, 69 
examination of, 15. 68, 7<> 
fibroma of, 69 
minima of, 69 
haematoma of, 69 
herpes of. 69 
hypertrophy of. 69 
i 111 pert' orate, 69 
injuries of, 69 
karorosis of, 69 
lacerations of, 69 
lipoma of, 69 
lupus of, 69 
mucous patch of. 69 
myoma of, 69 
oedema of, 69 
sarcoma of, 69 
syphilis of, 69 
tumors of, 68 

varicose veins of, rupture of, 69 
venereal warts, 69 
Vulvitis, gonorrhoeal, 69 
purulent. 69 

W 

Waiting-room, adjoining mortuary, 11 
Walls, gastric, atony of, 191 
Warm abscess, synonyms of, 461 
Warmth, vital, rapidity of loss of, 48, 49 
delayed, 48, 49 
hastened, 48, 49 
Wart, anatomic, 44, 318 

cause of general tuberculosis, 44 
treatment of, 44. 45 
-yphilitic, 307 
venereal, of vulva, 69 
Washing tissues for preservation, 342 
Water, effect of, on lowering temperature 
of corpse, 49 
presence of, in body, 360 
use of. in cleaning parts, 10 
Waxy degeneration of voluntary muscles 

in typhoid fever, 318 
Webbed fingers and toe-. 68 
Weigert's -tain, 341 
Weighing, proper time for, 357 
Weight, American insurance standard of, 

and measurement of child at birth, 358 
foetus, 350 

nutrition, -o 



INDEX 



Weight, approximate, of internal organs, 
360 
average, of brain stem, 362 
of cerebellum, 362 
cerebrum, 362 
new-born, 358 
avoirdupois, 357 
greatest, attained by man, 358 
how expressed, 17 
maximum, of encephalon, 361 
of adrenal bodies, 369 

arachnoid and pia, 462 
bladder, 368 

body, by percentage, 360 
breasts at birth, 372 

during lactation, 372 
of adult, 372 
heart, 364 
kidney, 367 
large intestine, 366 
liver, 366 
lungs, 365 

maxillary glands, 366 
new-born, 358 
oesophagus, 366 
ovaries, 370 
pancreas, 369 
pia and arachnoid, 462 
pineal gland, 363 
pituitary gland, 363 
placenta, 359 
prostate, 372 
small intestine, 366 
spinal cord, 364 
spleen, 162, 369 
stomach, 366 

supernumerary livers, 367 
suprarenals, 369 
testes, 370 
thymus gland, 370 
thyroid gland, 370 
uterus, 371 

vermiform appendix, 366 
Troy, 357 
Weil's disease, 458 
Wharton, gelatin of, 276 
Whetstone, 33 

White swelling, synonyms of, 450 
Whitish discoloration of mucous mem- 
branes by corrosive alkalies, 423 
Whooping-cough, 351, 448 
Widal test, 169 

for distinguishing human blood, 

120 
how made at postmortem, 319 
Williams case, 420 
Winslow's test for respiratory movement, 

47 
" Wish-bone," 394 
Wooden tongue, 290 
Woodhead's method for examining ear, 

258 
Worms, intestinal, in peritoneal cavity, 88 



INDEX 



55 1 



Wounds, iv, p. 38 
character of, 408 
gunshot, in violent death, 408 
most liable to become infected, 43 
oi hands protected before postmor- 
tem. 38 
pericardium and heart, 99 
post-mortem, character of, 41 
how caused. 42 
results of. 41 
treatment of, iv, p. 38 

by antiseptic dressing. 45 
bleeding. 43 
bromin, 43 
carbolic acid, 43 
caustics, 43 
cautery, 43 
Crede's ointment. 44 
flax and poultices, 44 
glacial acetic acid, 43 
hemorrhage, as a thera- 
peutic measure. 43 
Hume's intravenous in- 
jection, 44 
intravenous injections. 44 
iodin. 44 

silver nitrate solution, 44 
sucking of. 43 
virulence of. explained, 42 
virulent kinds of, 41 
Wright's electrical engine. 30 
Wrisberg's ganglion, 276 



Xanthoma, 64 
Xerosis bacillus, 350 
Xiphopagus, 67 

X-rays, effect of, on anatomic wart, 45 
guinea-pigs, 261 
photographic plates, 261 
in arsenical poisoning, 429 

examination of bones and joints, 
261 
medicolegal uses of, 413 
no death yet attributed to, 413 
sterility caused by, 211, 414 
use of, in detecting movement of heart 
and lungs, 47 



Yaws, 296 

Yellow atrophy, acute, of liver, 213 
fever, 319, 351, 373, 449 

lesions in, 319 

mosquito in, 319 

organisms of, 351 



Z 



Zenker's fluids, 333, 334, 338 
Zinc salts, toxicology of, 423 

chlorid, for hardening brain, 241 




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